ECM Care Coordinator (LVN) – Job Description 

The ECM Care Coordinator (LVN) supports Enhanced Care Management (ECM) services by coordinating care for patients with complex medical and social needs. The LVN works closely with case managers, providers, and the interdisciplinary care team to ensure patients receive coordinated, patient-centered care. 

Key Responsibilities 

• Assist with outreach, engagement, and enrollment of ECM members.
• Support the development and implementation of individualized care plans in collaboration with case managers, providers, and other care team members.
• Review and update care plans as needed based on patient needs, progress, and provider recommendations.
• Participate in and help coordinate ICT to discuss patient progress, barriers to care, and care plan updates 

Monitor patient progress and follow up on referrals, medications, appointments, and treatment plans.
• Assist with care transitions, including hospital discharge follow-ups and coordination of specialty care.
• Identify social determinants of health needs and connect patients with community resources.
• Document all patient interactions, care plan updates, and ICT participation accurately in the electronic health record system.
• Collaborate with physicians, behavioral health providers, case managers, and community partners to support patient care.
• Ensure compliance with ECM program requirements, clinic policies, and HIPAA regulations.
• Participate in team meetings, quality improvement initiatives, and ECM program activities. 

Additional Key Responsibilities 

• Complete daily member outreach calls and follow-up calls to meet established productivity and outreach targets. 
• Make outbound phone calls to engage members, schedule appointments, provide education, coordinate services, and support care plan goals. 
• Assist the ECM team in achieving monthly outreach, engagement, and enrollment targets by maintaining consistent call volumes and timely follow-up. 
• Monitor assigned work queues and prioritize outreach activities to ensure all required contacts are completed within program timelines. 
• Accurately document all phone calls, member interactions, and care coordination activities in the electronic health record (EHR) on the same day of service. 
• Assist with additional administrative and care coordination tasks as assigned to support department goals and member care. 

Qualifications 

• Active California LVN license in good standing.
• Experience in care coordination, case management, or community health preferred.
• Knowledge of Medi-Cal ECM program requirements preferred.
• Strong communication, documentation, and organizational skills.
• Ability to work effectively with multidisciplinary teams and diverse patient populations. 

Core Competencies 

• Care coordination and patient advocacy
• Care plan development and follow-up
• Participation in ICT meetings and care collaboration
• Patient engagement and outreach
• Time management and organization
• Knowledge of community resources and social services 

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