Lead Care Manager- CalAIM Services

Lead Care Manager- CalAIM Services - Four Openings

The Lead Care Manager provides comprehensive, person-centered care coordination to individuals enrolled in Enhanced Care Management (ECM) and Community Supports (CS) services. Working with high need, justice-involved, and/or housing insecure populations, the Care Manager delivers field-based services that address medical, behavioral health, and social determinants of health. This role is responsible for outreach, engagement, assessment, care planning, service linkage, and ongoing support to help members achieve stability, improve health outcomes, and maintain housing.

Qualifications

• 2-year degree in Social Work, Human Services, Sociology or a related field.


• Certified Community Health Worker or the ability to obtain certification within 12 months of hire


• Experience in providing CalAIM programs


• Experience in case management, care coordination, or social services, preferably with high-need or justice-involved populations


• Knowledge of housing resources, homelessness systems, and community-based services


• Familiarity with trauma-informed care, harm reduction, and person-centered practices


• Strong organizational, communication, and problem-solving skills


• Ability to work independently in community and field-based settings

Preferred Qualifications

• Knowledge of Medi-Cal systems and documentation requirements


• Experience using EHR or case management systems


• Bilingual English/Spanish

Key Responsibilities

Outreach, Engagement & Enrollment

• Conduct proactive, field-based outreach to locate, engage, and build trust with eligible members, including those experiencing homelessness or reentry from incarceration


• Perform outreach in a variety of settings, including streets, shelters, correctional facilities, hospitals, and community locations


• Educate potential members on ECM and Community Supports services and assist with enrollment


• Obtain and document required consents for services and data sharing in compliance with program requirements

Assessment & Care Planning

• Complete comprehensive assessments to identify member needs, strengths, risks, and goals


• Develop and implement individualized care plans and/or housing support plans that are person-centered and goal-oriented


• Continuously reassess member needs and update care plans based on progress and changing circumstances

Care Coordination & Service Linkage

• Coordinate care across physical health, behavioral health, housing, and social service systems


• Connect members to medical providers, behavioral health services, substance use treatment, and community-based resources


• Facilitate referrals and warm handoffs to ensure successful service linkage


• Advocate on behalf of members to reduce barriers and improve access to services

Housing Support (Community Supports)

• Conduct housing assessments and assist members in identifying and securing safe and stable housing


• Support completion of housing applications, documentation collection, and access to housing resources


• Assist with securing housing deposits, utilities, and other one-time needs necessary for move-in


• Provide tenancy support, including landlord communication, eviction prevention, and crisis intervention


• Educate members on tenant rights, responsibilities, and independent living skills

Ongoing Support & Case Management

• Maintain regular contact with members based on acuity and service requirements


• Provide coaching and support in areas such as budgeting, life skills, and health management


• Monitor member progress and adjust interventions as needed


• Participate in multidisciplinary team meetings and case consultations

Documentation & Compliance

• Maintain accurate, timely, and complete documentation in electronic health record (EHR) systems


• Document all outreach, assessments, care plans, progress notes, and service activities in accordance with program standards


• Ensure compliance with HIPAA, confidentiality, and data-sharing requirements


• Support billing and reporting processes by ensuring documentation meets required standards

Collaboration & Communication

• Work collaboratively with multidisciplinary team members, including clinical consultants and supervisors


• Coordinate with Managed Care Plans (MCPs), housing providers, community-based organizations, and other partners


• Participate in trainings and maintain knowledge of ECM, Community Supports, and CalAIM requirements


• Other duties as assigned