Master of Social Work (MSW)

Illumination Health + Home•Riverside, CA

2d•$72,000 - $79,040•Onsite

About The Position

The Behavioral Health Worker supports Illumination Health + Home’s Enhanced Care Management (ECM) program in the Riverside region through community-based behavioral health engagement, screening support, referral coordination, and follow-up for members with mental health, substance use, and complex social needs. The position works within a multidisciplinary ECM team and supports the assigned Lead Care Manager (LCM), who retains responsibility for overall member care coordination and the Care Management Plan. This is a non-clinical coordination role unless the employee holds additional credentials and is expressly authorized to perform clinical functions. The role does not independently diagnose, provide psychotherapy, or make clinical treatment decisions. The position is primarily community-based and in person within the Riverside service region, with phone or telehealth used when appropriate. The role includes behavioral health engagement and approved screening support; referral and warm-handoff coordination; follow-up after treatment referrals and transitions of care; collaboration with the LCM and multidisciplinary team; and accurate, timely documentation of ECM services and encounters. The worker must escalate safety concerns and significant clinical changes to licensed staff, follow applicable privacy and consent requirements, and complete required training and program competencies.

Requirements

Bachelor’s degree in Social Work, Psychology, Behavioral Health, Human Services, Counseling, or a closely related field; an equivalent combination of relevant education and direct service experience may be considered.
At least two years of experience providing behavioral health support, case management, community-based outreach, care coordination, or related direct services to individuals with complex health and social needs.
Knowledge of mental health and substance use disorders, behavioral health treatment and referral pathways, trauma-informed care, crisis recognition and escalation, confidentiality requirements, and professional scope-of-practice boundaries.
Ability to conduct regular in-person community visits throughout the Riverside service region.
Reliable transportation and ability to meet applicable driving requirements when driving is an essential job duty.
Proficiency with electronic health records or care management documentation systems, timely case notes, referral tracking, and accurate service encounter documentation.
Ability to collaborate with Lead Care Managers, nurses, licensed behavioral health providers, and community partners.
Willingness to complete required onboarding, screening-tool training, and ongoing program competencies.

Nice To Haves

Master of Social Work (MSW) degree from a CSWE-accredited program; strongly preferred.
Active California Associate Clinical Social Worker (ASW) registration with the Board of Behavioral Sciences; highly desirable.
MSW graduates eligible to pursue ASW registration are encouraged to apply. Clinical duties assigned to an ASW require appropriate supervision, authorization, and compliance with California scope-of-practice rules.
Experience with Medi-Cal, CalAIM ECM, homelessness services, serious mental health needs, substance use disorders, and behavioral health treatment coordination.
Experience with PHQ-9, BAM, motivational interviewing, trauma-informed care, crisis identification, and multidisciplinary teams.
CHW or peer support certification, where relevant to the applicable staffing classification.
Bilingual English/Spanish.

Responsibilities

Build trusting, culturally responsive relationships through trauma-informed, person-centered engagement and motivational interviewing.
Conduct in-person member visits at shelters, housing sites, healthcare facilities, and other appropriate community settings in Riverside County; use phone or telehealth when appropriate.
Identify barriers to treatment, including transportation, housing instability, provider access, and difficulty navigating services.
Coordinate with the LCM to re-engage members with unmet behavioral health needs and document outreach and outcomes.
Assist with approved behavioral health screening and monitoring, including PHQ-9 and Brief Addiction Monitor (BAM), only when trained and authorized.
Promptly communicate concerning screening findings, deterioration, substance-related risks, and other changes to the LCM and appropriate licensed practitioner.
Follow IHH crisis and emergency procedures for imminent safety concerns; do not independently diagnose or determine treatment.
Track assigned follow-up activities and communicate changes in member functioning and needs to support measurement-based care.
Coordinate referrals and warm handoffs to outpatient mental health, psychiatry, specialty mental health, Drug Medi-Cal/SUD services, crisis resources, and community supports.
Track referrals through scheduling, linkage, follow-up, or documented barriers, and report gaps to the LCM.
Collaborate with the LCM on behavioral health goals in the member’s Care Management Plan and support monthly updates and status changes.
Assist with transitions after ED visits, hospitalization, psychiatric care, or detoxification, coordinating required post-discharge follow-up with the LCM.
Participate in multidisciplinary team conferences, case discussions, practice coaching, and coordinated service planning.
Work with nurses, medical providers, LCMs, community health workers, and external behavioral health providers while respecting role boundaries.
Maintain community-based, in-person availability within the contracted Riverside service region.
Accurately document each ECM service, outreach attempt, referral, and follow-up in the designated care management documentation system (CMDS) or approved alternative.
Submit timely documentation for encounter reporting; report every ECM service using the applicable HCPCS code and staff classification.
Coordinate with the LCM to support at least two qualifying ECM services per enrolled member per calendar month; this is a team-level engagement requirement, not two behavioral-health visits by this worker.
Follow privacy and consent requirements, including HIPAA, California confidentiality laws, and 42 CFR Part 2 where applicable.
Maintain accurate records supporting audit readiness, service quality, and non-duplication of care management services.
Maintain professionalism, confidentiality, respectful communication, and sound judgment in member and partner interactions.
Escalate urgent safety concerns immediately and other significant clinical concerns promptly to licensed staff.
Complete assigned service documentation within 24–48 hours under IHH internal expectations, or within shorter applicable plan deadlines.
Participate in required program webinars, monthly practice coaching, and semiannual learning sessions.
Complete care management documentation system introductory training within 30 business days of hire when applicable.
If classified as a Community Health Worker on the ECM care team, complete the required nine-week CHW curriculum or an approved equivalent.
Support continuous improvement, reliable referral follow-up, and timely communication with ECM leadership.

Benefits

Medical insurance funded by Illumination Health + Home (Kaiser and Blue Shield), depending on the plan.
Dental and vision insurance.
Life, AD&D, and LTD insurance funded 100% by Health + Home.
Employee Assistance Program.
Professional Development Reimbursement.
401(k) with company matching.
10 days vacation PTO per year.
6 days sick PTO per year.
10 days holiday PTO per year.
Potential eligibility for the Public Service Loan Forgiveness Program for federally qualified loans.