ECM Lead Case Manager

Axis Senior Resource - Rocklin, CA

Full-time - Mid Level

Rocklin, CA

Professional, Scientific, and Technical Services

About the position

The Lead Case Manager is responsible for coordinating comprehensive, person-centered care for individuals with complex health and social needs. This role involves collaborating with healthcare providers, social services, and community organizations to ensure individuals receive necessary services and support for improved health outcomes. Key aspects include developing individualized care plans, monitoring patient progress, and advocating for resources to address medical, behavioral health, and social needs.

Responsibilities

• Assess patient needs and develop personalized care plans that address physical, behavioral, and social determinants of health.
• Facilitate care coordination across a variety of healthcare settings (e.g., hospitals, clinics, outpatient services) and community-based resources.
• Monitor patient progress and adjust care plans as needed to ensure optimal health outcomes.
• Advocate for patients to access healthcare services, resources, and support.
• Provide education and coaching to patients and their families about managing chronic conditions, understanding treatment options, and navigating the healthcare system.
• Empower patients to make informed decisions about their care and wellness.
• Work closely with multidisciplinary teams, including medical clinicians, social workers, and mental health providers, to ensure coordinated care delivery.
• Collaborate with community organizations, support groups, and government agencies to identify and secure resources such as housing, transportation, and health care services.
• Maintain accurate records of patient interactions, assessments, and care plans in compliance with healthcare regulations and organization policies.
• Utilize records system to track patient outcomes, identify care gaps, and ensure quality standards are met.
• Participate in regular case reviews and data analysis to monitor program effectiveness and improve care processes.

Requirements

• Strong organization skills
• Excellent communication skills
• Competent with computer use
• Ability to multi-task
• Ability to take action when there is a sense of urgency