Recuperative Care- Case Manager

Whole Person Care Clinic • Sacramento, CA

1d • Onsite

About The Position

The Case Manager provides direct, trauma-informed case management services to individuals experiencing homelessness and to patients enrolled in Recuperative Care (also known as Medical Respite) programs. This role serves as a critical bridge between acute medical care, behavioral health care, housing stability, and community-based support services, guiding clients through complex systems with compassion and advocacy. In addition to demonstrating professionalism and reliability, the ideal candidate brings a working knowledge of local community resources, a foundational understanding of medical and behavioral health terminology, and care settings, and a basic familiarity with Medi-Cal insurance and eligibility processes.

Requirements

• Bachelor's degree in social work, Psychology, Public Health, Human Services, or a related field - OR - equivalent combination of education and relevant work experience.
• Minimum 1-2 years of case management or social services experience, preferably in homeless services, recuperative/medical respite care, or a similar setting.
• Demonstrated knowledge of local community resources and social service systems.
• Ability to work effectively with individuals experiencing homelessness, mental illness, substance use disorders, and complex medical conditions.
• Proficiency in basic computer applications and electronic case management systems.
• Valid driver's license and reliable transportation (if required for client transport duties).

Nice To Haves

• Experience in a medical respite, skilled nursing, hospital, or clinic settings.
• Familiarity with Medi-Cal/Medicaid systems, managed care plans, and/or benefits enrollment.
• Bilingual or multilingual skills (Spanish strongly preferred).
• Certification in Mental Health First Aid, CPR/First Aid, or Motivational Interviewing.
• HMIS or comparable database experience.

Responsibilities

• Conduct comprehensive intake assessments to identify clients' housing, medical, behavioral health, social, and basic needs.
• Develop individualized service plans with measurable goals in collaboration with clients, clinical staff, and partner agencies.
• Provide regular case management check-ins, adjusting service plans as client needs evolve.
• Facilitate coordination of care for clients with existing service providers, including prompt and reliable communication with outside agencies and service providers.
• Maintain accurate, timely case notes and documentation in the agency's case management information system (HMIS or equivalent).
• Coordinate safe discharge planning for Recuperative Care patients transitioning back to community settings, including ensuring continuity of care upon discharge.
• Support clients to self-advocate with landlords, government agencies, healthcare providers, and social service systems, intervening to assist and advocate on behalf of client as appropriate.
• Have a working knowledge of and maintain an up-to-date database of local resources, including but not limited to housing programs, basic needs services, behavioral health providers, domestic violence support, legal services, employment/vocational programs, transportation services, etc.
• Build and maintain referral relationships with community partners to facilitate continuity of care.
• Connect clients to benefits they are entitled to, including SSI/SSDI, CalFresh, and CalWORKs.
• Understand and communicate basic medical information relevant to client care, including common diagnoses seen in the unhoused population (e.g., wound care needs, diabetes management, post-surgical recovery).
• Understand and communicate basic behavioral health information relevant to client care, including common diagnoses seen in the unhoused population (e.g., substance use withdrawal management, commonly misused substances, brief behavioral health intervention techniques, common mental health disorders, coping skills development).
• Accurately document observations and behaviors using appropriate medical and behavioral health terminology, communicating to nursing, clinical, and support staff in a timely manner.
• Monitor client adherence to prescribed treatment plans, medication schedules, and engagement in care, reporting concerns to clinical supervisors.
• Coordinate follow-up medical and behavioral health appointments and assist clients with transportation to health care visits.
• Recognize signs of medical distress or behavioral health crises and respond according to established protocols.
• Assist clients in applying for and maintaining Medi-Cal coverage, including Covered California where applicable.
• Demonstrate a basic understanding of Medi-Cal eligibility categories, managed care plans, and covered services.
• Help clients understand their insurance benefits and connect them with covered services such as pharmacy, mental health care, substance use disorder treatment, and specialist care.
• Coordinate with Medi-Cal managed care plan care coordinators and other service providers when appropriate to avoid duplication of services.
• Refer clients to a benefits specialist or social worker for complex insurance issues beyond the scope of this role.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level