About this role
The ECM Case Manager (LCSW or LMFT) provides clinically informed care management, under the supervision and direction of the Manager, Strategy & Operations & RN Clinical Consultant, to a caseload of high-need Medi-Cal members enrolled in Astrana Health’s Enhanced Care Management (ECM) program. This role supports members with chronic health conditions, behavioral health needs, substance use disorders, homelessness, or frequent hospitalizations by coordinating care, closing gaps in services, and connecting members to clinical and community-based resources. The ECM Case Manager (LCSW or LMFT) works cross-functionally with internal teams, community-based organizations, and health plan partners to improve health outcomes, reduce health disparities, and support continuity of care, directly advancing the ECM program’s quality, compliance, and member engagement goals.
- Caseload Management & Member Engagement Manage an assigned caseload of members with complex medical, behavioral, and social needs across multiple health plan contracts.
- Conduct outreach for members regardless of case assignment and regardless of any health plan to support team goals for ECM program engagement.
- Meet with members in person — including home visits, provider office visits, and community-based settings — to build trust, complete assessments, review care plans, and support engagement for members who are difficult to reach telephonically and potentially prospective members.
- Support ECM program engagement through member outreach beyond individual caseload assignments as needed to meet team goals.
- Assessment, Care Planning & Documentation Conduct member outreach and complete initial comprehensive assessments, care plans, and interdisciplinary team conferences within specified timeframes set by ECM leadership team.
- Develop member-centered care plans with clear, measurable, and achievable goals (e.g., SMART goals), reviewing and updating goals regularly to reflect member progress.
- Support the RN Care Manager with clinical assessments, including comprehensive health assessments, medication reconciliation, post-hospital discharge assessments, and standardized screening tools (e.g., PHQ-9, GAD-7, Edinburgh Postnatal Depression Scale).
- Maintain accurate and timely documentation across case management software, Excel trackers, Monday.com boards, and health plan portals.
- Care Coordination & Team Collaboration Coordinate transitions of care, including post-hospital and skilled nursing facility follow-up.
- Communicate proactively with PCPs, specialists, behavioral health providers, hospitals, and community-based organizations to close the loop on referrals and prevent gaps in care during transitions.
- Review claims and authorizations and perform medication reconciliation in support of care coordination.
- Responsible for team-based approach working with both internal and external partners to support ECM program success.
- Responsible for individual caseload in addition to supporting ECM members for all contracted health plans.
- Member Support Services Connect members to social services, transportation, housing, food, and other community resources.
- Apply motivational interviewing, trauma-informed care, and harm-reduction approaches to support member engagement.
- Identify barriers to treatment adherence and adjust care plans accordingly.
- Educate members and caregivers on disease management and healthcare navigation.
- Quality & Compliance Monitor member progress and manage caseload activity on a weekly cadence, ensuring deliverables and outcomes are met.
- Participate in audits, quality reviews, and team meetings as required.
- Maintain accurate and honest timekeeping.
- Support fellow care managers by sharing best practices and contributing to a positive, accountable team culture.
- Other duties as assigned.