ECM CARE SPECIALIST

Description

JOB SUMMARY

The Enhanced Care Management (ECM) ECM Care Specialist provides advanced care management services for patients with highly complex medical, behavioral health, and social needs. In this role, the ECM Care Specialist serves as a resource within the ECM program, managing a panel of patients who require intensive coordination and advocacy. The position emphasizes direct patient care, comprehensive care planning, and collaboration with multidisciplinary teams to reduce barriers, improve outcomes, and promote whole-person care. The ECM Care Specialist also supports program quality by modeling best practices, contributing to workflows, and sharing expertise with colleagues. 

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Carry an assigned patient caseload, focusing on individuals with the highest level of medical, behavioral, and social complexity.
• Conduct comprehensive assessments, develop individualized care plans, and coordinate care across medical, behavioral health, and social service systems.
• Provide intensive care coordination, including frequent follow-up, home visits, and outreach to ensure patient engagement.
• Serve as a resource for colleagues by providing guidance on complex cases and sharing knowledge of care coordination strategies, community resources, and patient engagement.
• Periodically review care plans for assigned patients to ensure completeness, accuracy, and alignment with patient goals and ECM standards.
• Monitor patient progress toward care plan goals, identify barriers to care, and adjust interventions as appropriate.
• Assist patients in navigating healthcare systems, accessing benefits, and connecting to community resources.
• Educate and empower patients to manage their health conditions and participate in care decisions.
• Collaborate with multidisciplinary care teams, including healthcare providers, behavioral health specialists, community health workers, and social service partners.
• Document all patient interactions, care plans, and progress accurately and in compliance with ECM program requirements.
• Participate in team meetings, case conferences, and quality improvement initiatives.
• Maintain confidentiality and comply with HIPAA and organizational policies.

Requirements

EDUCATION, TRAINING AND EXPERIENCE

• Bachelor’s degree in Social Work, Nursing, Public Health, Psychology, or related field required.
• Minimum 3 years of experience in care management, case management, or related field, with experience working with high-need or high-risk populations.
• Experience in healthcare, behavioral health, public health, or community health strongly preferred.  

KNOWLEDGE, SKILLS AND ABILITIES

• Strong knowledge of care management principles, patient-centered approaches, and social determinants of health.
• Advanced ability to conduct assessments, develop comprehensive care plans, and navigate complex systems of care.
• Skilled in communication, motivational interviewing, crisis intervention, and problem-solving with diverse patient populations.
• Proficiency in documentation, data entry, and use of electronic health records and case management systems.
• Ability to work independently and collaboratively within a multidisciplinary team.
• Strong organizational and time management skills to balance intensive caseload demands.
• Commitment to cultural humility, trauma-informed care, and health equity.
• Proficiency with Microsoft Office Suite and electronic health records.
• Ability to find solutions when barriers are identified.
• Strong documentation skills. 
• Ability to multi-task and prioritize when needed.
• Ability to independently seek out resources and work collaboratively.
• Ability to read, understand, and follow oral and written instructions. 
• Experience and work ethics that support working within a high-functioning, team-oriented environment.
• Demonstrates a willingness and ability to work under supervision.
• Ability to develop and maintain good working relationships with staff.
• Ability to use computers and learn new software programs.
• Excellent interpersonal skills reflecting clarity and diplomacy and the ability to communicate accurately and effectively with all levels of staff and management.
• Demonstrates ability to work in a regulatory climate that includes oversight of state and federal entities, payer contracts etc.
• Possesses the ability to communicate effectively, both verbally and in writing.
• Possesses genuine respect for others and acceptance of their individual social and cultural traits.
• Proficient knowledge of Microsoft Outlook.
• Able to travel and attend professional meetings, conferences, training, and other clinic sites. 
• Demonstrate flexibility, enthusiasm, and willingness to cooperate while working with others in multi-disciplinary teams.
• Performs other related duties as assigned.

PHYSICAL DEMANDS

Position requires prolonged sitting at a computer, some bending, lifting, stooping and stretching. Good eye-hand coordination and manual dexterity sufficient to operate a computer keyboard, photocopy machine, telephone, and other office equipment is also required. Employee must have normal range of hearing and eyesight.

NOTE: The essential job functions for this position include, but may not be limited to those listed in this job description. Employees hired for this position must be able to perform the essential functions of this job without imposing significant risk of substantial harm to the health or safety of themselves or others.