Lead Care Coordinator

POSITION SUMMARY: The Lead Care Coordinator serves as the primary care manager for Medi-Cal Members enrolled in the Enhanced Care Management (ECM) program. This role functions as the central point of contact for the Member their family Authorized Representative (AR) caregiver(s) and multidisciplinary care team. The Lead Care Coordinator delivers whole-person culturally responsive care by addressing medical behavioral developmental oral health and social needs through collaboration with internal staff and external partners. This position plays a key role in expanding access to services and ensuring compliance with Department of Health Care Services (DHCS) and Managed Care Plan (MCP) ECM requirements.

DUTIES:

Care Planning

1. Use comprehensive assessments to develop individualized care plans addressing physical health behavioral health substance use oral health trauma housing employment and social support needs.
2. Collaborate with the Member family caregivers and care team to maintain a whole-person care plan.
3. Reassess and update care plans at least every six (6) months or as the Members needs change.

Care Coordination & Integration

1. Serve as the primary point of contact for the Member family authorized representative caregiver(s) and multidisciplinary care team.
2. Coordinate communication and services among providers community partners and MCP representatives to ensure seamless and non-duplicative care.
3. Facilitate warm handoffs between care settings including hospital discharges and other transitions.
4. Work with the ECM Clinical Consultant (licensed clinician) for oversight guidance and clinical support.

Service Delivery & Support

1. Provide all ECM Core services as defined by DHCS includingoutreach and engagement comprehensive assessment and care planning enhanced care coordination health promotion transitional care services member and family support referral and linkage to community/social support services
2. Provide education to Members and families about care plans treatment options and self-management strategies.
3. Deliver services in the Members preferred setting (field home community office or telehealth).
4. Requires field-based work home visits or travel within the service area. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Documentation & Compliance

1. Maintain accurate timely and complete documentation in accordance with agency MCP and DHCS requirements.
2. Ensure all reports assessments and care plans meet ECM quality and data submission standards

Cultural & Linguistic Responsiveness

1. Provide services consistent with DHCS Culturally and Linguistically Appropriate Services (CLAS) standards.
2. Demonstrate respect for diverse cultural values beliefs and linguistic needs.

Team Collaboration & Training

1. Participate in regular supervision case reviews and multidisciplinary team meetings.
2. Support and guide care team members to ensure coordinated delivery of ECM services.
3. Attend required trainings and maintain up-to-date knowledge of CalAIM ECM and care coordination best practices.