Care Manager -In person-Riverside

Partners in Care Foundation In•Riverside, CA

11d•$21 - $25•Onsite

About The Position

The Care Manager is responsible for providing person-centered care management services to eligible members with medical, behavioral health, or social needs. This role includes outreach, engagement, assessment, care planning, care coordination, service navigation, and ongoing follow-up. The Care Manager maintains an active caseload and works collaboratively with health plans, community partners, service providers, and internal staff to reduce barriers, improve access to services, and support members in achieving their wellness goals.

Requirements

High school diploma and equivalent work or lived experience serving similar populations.
Minimum of 1–2 years of experience in case management, community outreach, social services, behavioral health support, or similar member-facing work.
Experience working with individuals experiencing homelessness, medical complexity, behavioral health needs, or social barriers.
Bachelors required in social work, psychology, gerontology, public health or related field.

Nice To Haves

Experience with Medicare/DSNP, Medi-Cal or safety-net healthcare environments.
Bilingual/bicultural skills.

Responsibilities

Conduct outreach and engagement activities to connect eligible members with services.
Perform comprehensive assessments capturing member needs related to medical care, behavioral health, housing, transportation, benefits, and social determinants of health.
Develop person-centered care plans with member input that reflect goals, strengths, barriers, and service coordination needs.
Provide ongoing care coordination, warm hand-offs, education, and advocacy to support member progress.
Facilitate communication among member support systems, including healthcare providers, social service agencies, health plans, behavioral health, and housing programs.
Conduct field-based activities, including home visits, office visits, and community outreach.
Use motivational interviewing, trauma-informed care, and culturally responsive approaches to engage members with varying levels of readiness.
Assist members in accessing transportation, scheduling appointments, applying for benefits, and connecting with appropriate programs or services.
Support transition activities such as hospital discharge coordination, navigating new providers, or connecting to long-term supports.
Maintain timely and accurate documentation in accordance with internal and external programmatic standards.
Track member progress toward goals through case notes, care plan updates, and authorized service logs.
Meet required engagement, visit, and contact frequency benchmarks based on acuity and program guidelines.