Care Coordinator

Are you motivated to make a difference for your community? Care Coordinators are specialists trained to engage folks who have been left out of the healthcare system. Partners has specialized in addressing the social drivers of health for over 25 years and through our ECM program we reach out to the most vulnerable and in-need throughout the county. Join us and become a part of a team making a difference in LA

Hybrid position. Makes in person client visits in homeless encampments, shelters, and homes.

The ECM Care Coordinator is responsible for providing person-centered Enhanced Care Management services to eligible Medi-Cal members with complex medical, behavioral health, or social needs. This role includes outreach, engagement, assessment, care planning, care coordination, service navigation, and ongoing follow-up. The ECM Care Coordinator maintains an active caseload and works collaboratively with health plans, community partners, service providers, and internal staff to reduce barriers, improve access to services, and support members in achieving their wellness goals.

Key Responsibilities

Core ECM Service Delivery

• Conduct outreach and engagement activities to connect eligible members with ECM services.
• Perform comprehensive assessments capturing member needs related to medical care, behavioral health, housing, transportation, benefits, and social determinants of health.
• Develop person-centered care plans with member input that reflect goals, strengths, barriers, and service coordination needs.
• Provide ongoing care coordination, warm hand-offs, education, and advocacy to support member progress.
• Facilitate communication among member support systems, including healthcare providers, social service agencies, health plans, behavioral health, and housing programs.
• Conduct field-based activities, including home visits, office visits, and community outreach.

Member Support & Engagement

• Use motivational interviewing, trauma-informed care, and culturally responsive approaches to engage members with varying levels of readiness.
• Assist members in accessing transportation, scheduling appointments, applying for benefits, and connecting with appropriate programs or services.
• Support transition activities such as hospital discharge coordination, navigating new providers, or connecting to long-term supports.

Documentation & Compliance

• Maintain timely and accurate documentation in accordance with DHCS, managed care plan, and organizational standards.
• Track member progress toward goals through case notes, care plan updates, and authorized service logs.
• Meet required engagement, visit, and contact frequency benchmarks based on acuity and program guidelines.

Qualifications

Required:

• Associate degree in Human Services, Social Work, Public Health, Behavioral Health, or related field OR equivalent work or lived experience serving similar populations.
• Minimum 1–2 years of experience in case management, community outreach, social services, behavioral health support, or similar member-facing work.
• Experience working with individuals experiencing homelessness, medical complexity, behavioral health needs, or social barriers.

Preferred:

• Bachelor's degree in a related field.
• Experience with Medi-Cal or safety-net healthcare environments.
• Bilingual/bicultural skills.

Skills & Competencies

• Strong interpersonal skills and ability to build trust with diverse populations.
• Knowledge of community resources, housing programs, social supports, and care coordination practices.
• Ability to work independently, prioritize responsibilities, and maintain boundaries.
• Strong written and verbal communication skills.
• Proficiency with electronic records and mobile work tools.

Work Environment

• Field-based role with regular travel for home visits, community coordination, and partner meetings.
• Must have reliable transportation and proof of California required auto liability insurance.
• Ability to  meet member safely in community settings.

Partners in Care Foundation is an equal opportunity employer.  We are committed to complying with all federal, state, and local laws providing equal employment opportunities, and all other employment laws and regulations. It is our intent to maintain a work environment which is free of harassment, discrimination, or retaliation because of age, race (including hair texture and protective hairstyles, such as braids, locks, and twists), color, national origin, ancestry, religion, sex, sexual orientation, pregnancy (including childbirth, lactation/breastfeeding, and related medical conditions), physical or mental disability, genetic information (including testing and characteristics, as well as those of family members), veteran status, uniformed service member status, gender, gender identity, gender expression, transgender status, arrest or conviction record, domestic violence victim status, credit history, unemployment status, caregiver status, sexual and reproductive health decisions, salary history or any other status protected by federal, state, or local laws.  All qualified applicants will receive consideration for employment and reasonable accommodations may be made to enable qualified individuals to perform the essential functions of the position.