Behavioral health Case Manager (Clinical Social Worker)

Zócalo Health

1d•$78,000 - $90,000•Remote

About The Position

Zócalo Health is a tech-enabled, community-oriented primary care organization serving people who have historically been underserved by the one-size-fits-all healthcare system. We partner with health plans, providers, and community organizations to deliver culturally competent primary care, behavioral health, and social care. Our model is built for populations with high medical and social complexity, where fragmented care drives poor outcomes and unnecessary cost. We combine local, community-based teams with virtual care and modern technology to deliver coordinated, whole-person care where members live and receive support. Founded in 2021, Zócalo Health is backed by leading healthcare and mission-aligned investors and is scaling rapidly across states and populations. We are building a durable care platform designed to perform in constrained healthcare environments and to lead the shift toward accountable, value-based care. Our care model is designed to meet members wherever they are—whether in their homes, online, or in their community. Behavioral Health Case Managers are integral to our mission of providing culturally aligned and accessible care to the Latino community. They build trust through shared cultural and linguistic backgrounds, improving member engagement and access to care. Zócalo Health is seeking a behavioral health case manager to serve as the primary point of contact for an assigned caseload of ECM members with behavioral health needs (including members with more complex mental health and/or substance use needs). This role provides relationship-based outreach, care navigation, care coordination, and brief skills-based behavioral health support to help members engage in appropriate services and move toward their goals. Note: This role focuses on engagement, care coordination, and brief support strategies, including referrals and warm handoffs to psychotherapy, psychiatry, and Specialty Mental Health. This position reports to the Senior Director of Clinical Operations. You will work primarily in your community, with some work-from-home responsibilities.

Requirements

Fluency (verbal and written) in English and Spanish.
Master’s degree in Social Work
Active, unrestricted Clinical Social Work License (LCSW)
1–3 years healthcare experience or healthcare navigation within the community.
Experience supporting members/patients with behavioral health needs (SMI/SUD exposure preferred).
Familiarity with Google Workspace (preferred).

Nice To Haves

Knowledgeable of Latino customs and cultural norms (preferred).
Past experience documenting in an EHR (preferred).
Training in motivational interviewing (preferred).
Comfortable working with multiple computer applications simultaneously and willingness to learn new technologies and frameworks.
Team player who builds effective working relationships.
Ability to train others (preferred).
Well-known in and have strong ties to the local Latino community (preferred).
Well versed in local resources to support SDOH needs (preferred).
Flexible and able to travel to other communities
Willing to travel to support community events and in person member appointments.
Have reliable sources of transportation.

Responsibilities

Play an active role in member registration and enrollment, including organizing community engagement and outbound outreach calls/texts.
Conduct outreach (virtually and in-person) to members scheduled for appointments and complete initial intake and readiness-to-engage check-ins.
Engage with a panel of assigned members to provide care navigation, appointment logistics, prescription drug support, lab support, referral coordination, care plan adherence support, and resource sharing.
Coordinate access to behavioral health services, including referrals and warm handoffs to psychotherapy, psychiatry, and Specialty Mental Health.
Assess for social determinants of health (SDOH) needs and enroll members in SDOH programs, including care planning development, referral to community resources, coaching, and graduation/transition planning.
Collaborate with a multidisciplinary care team to contribute to care plans, triage requests, and solve complex member needs.
Document all member and care team interactions across multiple systems and tools.
Participate in community events to support member activation and trust-building, including relationship-building with key contacts, facilitating group education sessions, and liaising with community organizations.
Provide culturally and linguistically appropriate health education and information.
Assist with federal and state support program enrollment, appointment scheduling, referrals, and promoting continuity of care.
Support individualized goal setting using motivational interviewing.
Conduct individual social needs assessments.
Provide social support by listening to member concerns and connecting them to appropriate support resources.
Attend and participate in community events as a Zócalo Health representative.
Coordinate internal clinical services.
Serve as the primary relationship holder for members with behavioral health needs; provide consistent outreach, follow-up, and re-engagement support, including after ED/inpatient discharge when applicable.
Use evidence-based engagement approaches (e.g., Motivational Interviewing) to support readiness for care, reduce barriers, and improve follow-through on shared care plan goals.
Provide brief, skills-based support aligned to member goals (e.g., behavioral activation strategies, coping skills coaching, and health literacy education related to behavioral health conditions and treatment options).
Provide brief crisis support within scope and protocol (e.g., de-escalation and safety check-ins) and complete warm handoffs to local crisis resources or higher levels of care when indicated.
Track and communicate behavioral health–related barriers, member goals, and key updates to the interdisciplinary team; participate in weekly case reviews and ad hoc case consultations.