Behavioral Health Care Manager – Street Medicine ECM

WEA CA PC•San Bernardino, CA

19d•$33 - $44•Onsite

About The Position

The Behavioral Health Care Manager is a specialized clinical and coordination role supporting Medi-Cal members with complex mental health, emotional, or substance use needs. Serving as the ECM Lead Care Manager, the position provides high-touch, person-centered coordination alongside street medicine clinicians. The Care Manager meets members face to face wherever they stay—including encampments, vehicles, shelters, and provider offices—and connects primary care, specialty care, behavioral health treatment, and community resources. The role supports members from first contact through stable housing and connected care. The position is field-based across Riverside and San Bernardino Counties, with work conducted primarily outdoors alongside the street medicine team. The population served includes people experiencing homelessness who also have complex health needs, including adults, families, or unaccompanied youth where applicable. Many members meet Serious Mental Health or substance use disorder criteria. The Care Manager delivers the seven ECM core service components: outreach and engagement; comprehensive assessment and care management planning; enhanced coordination of care; health promotion and behavioral support; comprehensive transitional care; member and family supports; and coordination of and referral to community and social support services. The role also provides measurement-based depression care management in partnership with members’ PCPs, street medicine clinicians, and a psychiatric consultant. The position documents encounters and outreach, completes assessments and care plans within required timeframes, supports accurate ECM billing and authorization tracking, and follows privacy, reporting, and compliance requirements. It includes field crisis intervention within scope and agency protocol, participation in team huddles and case conferences, and coordination around encampment resolutions to protect members’ continuity of care. Most of the workday is spent outdoors in encampments, riverbeds, vehicles, parks, and shelters, in heat, cold, rain, and smoke. The role involves extended walking, carrying supplies, and working on uneven terrain. Weekly individual supervision is provided by the Director of Behavioral Health, with daily huddles alongside street medicine clinicians and clinical consultation for complex cases.

Requirements

Master’s degree in social work, counseling, marriage and family therapy, psychology, or a closely related behavioral health field.
Direct experience serving people who are unhoused or housing insecure, ideally in street outreach, shelter, or housing programs.
Valid California driver’s license, reliable transportation, and current auto insurance for daily fieldwork.
Knowledge of CalAIM ECM requirements for the Individuals Experiencing Homelessness Population of Focus and housing-related Community Supports.
Knowledge of street medicine models and the role of care management within a field medical team.
Knowledge of Housing First, Coordinated Entry, HMIS, and local shelter and housing resources.
Knowledge of Medi-Cal delivery systems, including managed care, county Mental Health Plans (SMHS), DMC/DMC-ODS, and Medi-Cal Rx.
Knowledge of serious mental illness, co-occurring disorders, medications for addiction treatment, and harm reduction.
Knowledge of California involuntary treatment law (LPS/5150) and local crisis services.
Knowledge of public benefits and document recovery, including CalFresh, SSI/SSDI, GA, identification, and vital records.
Ability to build trust with members who have had poor experiences with systems.
Ability to assess risk and respond calmly to behavioral health crises in the field.
Ability to manage a caseload independently and prioritize by acuity and deadlines.
Ability to write clear, timely, audit-ready documentation.
Ability to coordinate with clinicians, hospitals, county staff, and landlords as both a peer and an advocate.
Ability to use an EHR or care management platform and basic office software.
Ability to work effectively with people across cultures, languages, gender identities, and life experiences.

Nice To Haves

BBS registration as an ASW, AMFT, or APCC, or progress toward licensure as an LCSW, LMFT, or LPCC.
Lived experience with mental health or substance use recovery.
Experience with Medi-Cal managed care, county SMHS/DMC-ODS, Coordinated Entry/HMIS, or reentry programs.
Bilingual in English and Spanish.
Training in person-centered planning.

Responsibilities

Join scheduled street medicine rounds to engage new members and relocate existing members in encampments, riverbeds, vehicles, parks, shelters, and drop-in sites.
Build trust through repeated contact using motivational interviewing, harm reduction, and trauma-informed engagement.
Coordinate with homeless outreach teams, shelters, and Coordinated Entry to locate members and document outreach attempts, methods, and locations.
Help members without active coverage begin Medi-Cal enrollment, including Presumptive Eligibility where available.
Complete whole-person field assessments covering physical health, mental health, substance use, oral health, social drivers of health, and housing needs.
Screen for suicide, overdose, medical risk, exposure, and wound concerns.
Develop and update person-centered care plans with housing goals and action steps.
Serve as Lead Care Manager and a single point of contact among street medicine clinicians, PCPs, county mental health and DMC-ODS, managed care plans, and housing providers.
Link members to behavioral health and substance use treatment, including medications for addiction treatment initiated by the street medicine team.
Help members find providers, schedule primary and specialty care, and arrange follow-up after hospital discharge.
Support adherence by helping replace lost medications and IDs, sending reminders, arranging transportation, and accompanying members to visits.
Provide therapeutic interactions within scope, including motivational interviewing and brief supportive counseling, to promote healthy behaviors and recovery goals.
Review medication adherence, side effects, and refills with members and coordinate with prescribers; do not prescribe or change medications.
Coach members on managing health conditions while unsheltered; distribute naloxone and other harm reduction supplies according to agency protocol and teach members how to use them.
Respond to ADT notifications and locate members after emergency department visits, hospital discharges, psychiatric holds, jail release, or sobering center stays.
Coordinate discharges to Recuperative Care or other safe settings instead of the street whenever possible.
With consent, engage members’ partners, family, and other chosen supports in care planning; serve families or unaccompanied youth as a unit where applicable.
Enter and update members in Coordinated Entry/HMIS and keep housing assessments current.
Refer members to and coordinate Community Supports, including Housing Transition Navigation, Housing Deposits, Housing Tenancy and Sustaining Services, Transitional Rent, Recuperative Care, Sobering Centers, and Medically Tailored Meals.
Connect high-risk members to food resources, childcare, and benefits such as CalFresh, SSI/SSDI, and GA; help members obtain identification and vital records.
Advocate with landlords, housing navigators, and property managers through move-in and early tenancy.
Provide measurement-based depression care management, including screening with the PHQ-2/PHQ-9 or age-appropriate tools, gathering relevant history, setting care-plan goals, and tracking outcomes.
Respond the same day to a positive PHQ-9 suicide item with a structured risk screen, safety planning, and escalation per protocol.
Deliver or link members to brief evidence-based interventions within scope, refer to appropriate behavioral health or substance use services, maintain a depression registry, and escalate cases not improving or worsening.
For members reaching depression remission, develop a relapse-prevention plan and continue monitoring before stepping down care.
Document every ECM encounter and outreach attempt, including date, mode, location, and core service component, in the designated care management system within required timeframes.
Complete assessments and care plans within MCP contract timeframes; enter accurate encounter and invoice data for ECM billing and do not bill for services not delivered.
Track member authorization periods and request reauthorization or discontinuation on time.
Share information only as permitted by HIPAA, 42 CFR Part 2, and member consent; report incidents, grievances, and suspected abuse according to agency policy and mandated reporter law.
Participate in MCP audits, chart reviews, corrective actions, team huddles, case conferences, clinical supervision, and MCP meetings.
Provide field crisis intervention within scope and protocol, including safety planning, warm handoffs to mobile crisis, and coordination around 5150 evaluations when indicated.
Coordinate with the team ahead of encampment resolutions or sweeps to protect members’ medications, documents, and continuity of care.
Assess members’ readiness to graduate from ECM using MCP-approved criteria and perform other duties within the scope of ECM.