Intensive Case Manager - Regional Care Coordination

Position Summary

Friendship Shelter is contracted by the Office of Care Coordination to provide Regional Care Coordination (RCC) in South Orange County. RCC is part of the county’s Homeless Service System and is designed to respond to and address the unsheltered homeless conditions in the region through comprehensive care coordination. The RCC Intensive Case Manager (ICM) will manage a varied caseload of participants, ranging from 15-20 participants. The RCC ICM will deliver targeted outreach and engagement, intensive case management, disability benefit application assistance and advocacy, housing navigation services, financial assistance to secure permanent housing, referrals to community resources including shelter and interim housing placements. Additionally, the ICM will provide community support services through the California Advancing and Innovating Medi-Cal (CalAIM) initiative, including Housing Navigation, Housing Stabilization, and Enhanced Care Management.

The RCC program prioritizes Chronically homelessness individuals who are high utilizers of the System of Care as identified by the Care Plus Program (CPP), general assistance or general relief applicants or recipients with disabilities who are experiencing homelessness, low-income individuals with disabilities who can be diverted from or who are being discharged from jails or prisons and who are experiencing homelessness or at risk of homelessness, low-income veterans with disabilities who are experiencing homelessness, low-income individuals with disabilities who are being discharged from hospitals or long-term care facilities who were experiencing homelessness prior to entry or are at risk of homelessness upon discharge.

In carrying out these responsibilities, the ICM is expected to reflect and advance Friendship Shelter’s core values by treating every client with dignity, respect, compassion, and empathy; building trusting and collaborative relationships; promoting equity and inclusion; maintaining professionalism and accountability; and approaching challenges with integrity and a solutions-focused mindset. The ICM will work collaboratively with clients, colleagues, healthcare providers, housing partners, and community-based organizations to ensure services are coordinated, responsive, and aligned with each client’s individual goals and needs.

Essential Job Duties and Responsibilities

· Conduct outreach and engage individuals experiencing unsheltered homelessness to determine eligibility and facilitate program enrollment through in-person meetings, mail, email, text, and phone communication.

· Provide ongoing services through regular in-person appointments, including assessments, care-plan development, service coordination, coaching, education, and referrals to community resources.

· Support client engagement by scheduling appointments, providing reminders, coordinating transportation, including driving clients to appointments, and addressing barriers to service engagement.

· Collaborate with the client's care team, including internal and external partners, to coordinate care, facilitate case conferencing, and make referrals.

· Maintain accurate and timely documentation, including case notes, case files, databases and financial documentation, to ensure compliance with RCC funding regulations and support CalAIM/Medi-Cal billing and project tracking.

· Foster positive relationships with staff, partner agencies, and community volunteers to enhance service delivery.

· Assist clients in securing and maintaining housing, providing advocacy and support for housing-related tasks.

· Enter data into HMIS, CalOptima Connect and other required databases, ensuring all records are accurate and up to date.

· Use a team approach to resolve housing barriers and respond to client crises as needed.

· Represent the organization in county-wide meetings and other forums as required.

· Provide instruction and assistance to improve clients' independent living skills, including budgeting, household care, and personal care.

· Connect clients to resources that enhance housing stability, such as employment, income benefits, medical care, mental health services, and legal aid.

· Participate in team and agency staff meetings.

Supervisory Responsibilities 

Direct Reports

   - This position does not have supervisory responsibilities for direct reports

Indirect Reports  

-  This position does not have guidance or mentoring responsibilities for  indirect reports

Driving Requirements

- Driving is an essential duty or function of this job. 

- Drive up to 50%

Minimum Qualifications 

The following are the minimum job-related qualifications which an individual needs in order to successfully perform the essential duties and responsibilities of the job.

· Case Management experience

· Experience working with individuals with severe and persistent mental illness, substance use disorder, or other disabling conditions.

· Must have a valid driver’s license and vehicle with valid registration and insurance.

· Desire to be a part of a team that is passionately committed to ending homelessness.

Skills, Knowledge and Abilities 

• Comfortable working in a Housing First, Trauma Informed, and Harm Reduction setting. 
• Ability to navigate the local Orange County social services arenas, such as Medi-Cal, CalOptima, food stamps/GR, ID services, social security and other social services or behavioral health providers. 
• Well organized, detail-oriented, and able to handle a fast-paced work environment. 
• Ability to understand and follow specific instructions and procedures. 
• Conflict management skills. 
• Decision-making skills. 
• Good interpersonal skills. 
• Ability to effectively communicate (verbal and written). 
• Basic computer skills, including Microsoft Word, PowerPoint, Excel, Teams, Outlook, and web browsers. 

Environmental & Physical Requirements 

Office / Field Non-Sedentary Requirements 

The employee must be able to perform the essential functions of the job. Work will be performed in shared spaces within the office environment and will involve interaction with clients out in the field. Typically requires the ability to spend 66%+ hours each workday doing the following activities: stand for extended periods of time, walk, bend, stoop, or climb. May require the ability to lift and/or push up to 25 pounds 33% - 66% of the time. Driving personal vehicle during work hours is required. 

Additional Information Regarding Friendship Shelter Job Duties and Job Descriptions 

Job duties include additional responsibilities as assigned by one’s supervisor or other manager related to the position/department. This job description is meant to describe the general nature and level of work being performed; it is not intended to be construed as an exhaustive list of all responsibilities, duties and skills required for the position. The Company reserves the right at any time with or without notice to alter or change job responsibilities, reassign or transfer job position or assign additional job responsibilities, subject to applicable law. The Company shall provide reasonable accommodations of known disabilities to enable a qualified applicant or employee to apply for employment, perform the essential functions of the job, or enjoy the benefits and privileges of employment as required by the law. 

Any estimate, schedule, or guideline provided to associates in this job description or elsewhere in connection with their jobs is intended to help describe job duties and for planning purposes. Regardless of any such estimate, schedule, or guideline, employees must always record all time worked for our company (which includes but is not limited to on-site work time at a shelter, office, or other work location; required waiting time; administrative time; and work-related travel time).