Job Summary:
The Enhanced Care Management (ECM) Clinician is responsible for member coordination, improving health outcomes, enhancing satisfaction, and reducing unnecessary healthcare utilization. ECM is a comprehensive, patient-centered approach to healthcare that aims to improve outcomes for high-need populations. This involves the coordination of medical, behavioral, and social services to address the full range of member needs, focusing on those with complex and chronic conditions. ECM programs are designed to optimize care delivery, reduce unnecessary hospitalizations, and improve the overall quality of life for members. The intention of our services is to help people who have not been able to get the needed help in terms of Housing, Mental Health, Substance Abuse treatment, and linkages to community resources to help minimize recidivism. The role of the ECM Clinical Case Manager provides integrated clinical and case management services to justice-involved individuals enrolled in Enhanced Care Management (ECM), with a primary focus on in-custody engagement within Orange County jail facilities and post-release community reintegration. This role delivers in-person assessments, pre-release planning, and clinical coordination inside the three Orange County jail facilities, while maintaining continuity of care through post-release case management, clinical touchpoints, and linkage to services in the community. The Clinical Case Manager operates as part of a multidisciplinary Orange County care team, supporting individuals with complex medical, behavioral health, substance use, and social needs. The goal is to improve health outcomes, reduce recidivism, and support successful transitions to stable housing, treatment, and long-term community integration. This position requires the ability to work effectively in secure custodial environments and field-based settings across Orange County, while adhering to all facility regulations and maintaining a high level of clinical and professional standards Essential Duties: Interview and conduct clinical assessments of member’s needs, including medical, behavioral, and social factors. Develop, implement, and monitor personalized care plans in collaboration with members, their families, healthcare providers, and community resources. Conduct outreach to identify and engage eligible in ECM services, using multiple strategies and modalities for engagement. Operate as part of the member’s multi-disciplinary care team. Facilitate regular team meetings to review patient cases, address challenges, and share successes. Travel locally to deliver services to members in the community where they live, work, or frequent. Document services in the agency’s Electronic Health Record within 72 hours of each service and in compliance with agency policy, as well as contractual, state, and federal regulations. Provide accurate daily and monthly documentation and case notes as per funding source guidelines. Attend workshops, meetings, and trainings as requested by supervisor. Provide in-person pre-release case management services within Orange County jail facilities , including conducting assessments, initiating care plans, and engaging members before release. Complete and maintain clearance for county jail access , including passing all required background checks and complying with facility-specific rules and regulations at all times. Adhere to all county jail visiting policies, procedures, and security protocols , demonstrating professionalism and compliance in a custodial setting. Deliver comprehensive pre-release planning , including development of individualized care plans, coordination of benefits, and linkage to housing, medical, and behavioral health services. Conduct in-person outreach, engagement, and ECM enrollment within Orange County jail facilities. Complete comprehensive biopsychosocial, Health Risk Assessments (HRA) to identify medical, behavioral health, and social service needs. Collaborate with custody staff and the multidisciplinary OC care team to coordinate care and ensure alignment of services. Deliver clinical interventions, including brief counseling, crisis intervention, and stabilization support as needed. Participate in case conferencing and provide clinical insight and recommendations for complex cases. Ensure compliance with all jail clearance requirements, security protocols, and visiting regulations. Community-Based & Post-Release Services Provide post-release follow-up and transition support, ensuring continuity of care from custody to community. Conduct post-transition touchpoints, including wellness checks and ongoing care coordination. Link clients to housing, medical care, mental health services, substance use treatment, and benefits (SSI, Medi-Cal, etc.). Schedule and coordinate medical and behavioral health appointments. Provide or coordinate transportation upon release, including transfers to housing placements, shelters, or family residences. Support