Director of Case Management and Care Coordination

CARDEA HEALTH•Oakland, CA

2d•$140,000 - $160,000•Onsite

About The Position

Cardea Health is seeking an experienced, strategic, and hands-on Director of Case Management and Care Coordination to lead and directly manage case management and care coordination functions across Cardea’s interim housing programs. The Director will supervise Care Coordinators and Behavioral Health Community Health Workers across sites and establish consistent baseline practices, service expectations, documentation standards, and accountability systems. The role will ensure that every resident receives timely and coordinated support at critical points, including intake, hospitalization, return from hospitalization, medical appointments, care transitions, and discharge. In addition to leading cross-site systems, the Director will carry a focused caseload of residents with particularly complex medical, behavioral health, housing, or social service needs. Working alongside housing, clinical, and program teams, the Director will provide intensive case support, help teams resolve barriers, and strengthen staff problem-solving skills over time. The Director will also lead performance improvement efforts by translating internal and externally reported outcomes into practical improvement plans. This includes identifying areas of underperformance, developing corrective strategies, supporting implementation across teams, and monitoring progress through completion. This position is well suited for a systems-oriented and collaborative leader who combines strong supervisory and operational skills with direct practice experience and a commitment to client-centered, trauma-informed, harm-reduction-oriented, and equitable care.

Requirements

Bachelor’s degree in social work, public health, health care administration, behavioral health, nursing, or a related field; equivalent relevant experience may be considered.
Five or more years of progressive leadership experience in case management, care coordination, health care operations, social services, housing services, or a related field.
Demonstrated experience directly supervising case management, care coordination, community health worker, or interdisciplinary service teams.
Demonstrated experience developing, implementing, standardizing, and monitoring case management or care coordination systems across teams or locations.
Experience providing direct support to individuals with complex medical, behavioral health, housing, substance use, or social service needs.
Experience leading interdisciplinary case planning and helping teams resolve complex service barriers.
Experience using data, performance metrics, and quality improvement methods to develop, implement, and monitor operational improvement plans.
Strong project management, organizational, staff development, and systems-building skills.
Ability to establish clear expectations, hold teams accountable, and support successful implementation and follow-through.
Excellent communication, collaboration, judgment, facilitation, and relationship-building skills.
Ability to work independently and manage multiple priorities in a fast-paced, multi-site, and evolving environment.
Proficiency with Microsoft Office Suite and experience working with electronic case management, health care, or human services data systems.

Nice To Haves

Experience managing interdisciplinary teams in health care, social services, housing, medical respite, or community-based settings.
Experience working within PACE programs or other integrated medical and social care models.
Experience leading care coordination or case management services in high-volume, multi-site environments.
Experience working with unsheltered populations and individuals experiencing homelessness.
Experience building and maintaining quality systems within rapidly growing organizations.
Experience with HMIS, health care or case management information systems, and outcome reporting.
Knowledge of trauma-informed care, harm reduction, housing-first principles, person-centered service delivery, and equitable decision-making.
Experience developing discharge protocols, behavioral agreements, complex-case review processes, or frameworks for planned and unplanned program exits.
Master’s degree in social work, public health, health care administration, nursing, or a related field.

Responsibilities

Provide direct management, supervision, coaching, and performance oversight for Care Coordinators and Behavioral Health Community Health Workers across Cardea sites.
Establish and maintain consistent baseline expectations for resident contact, follow-up, documentation, and care coordination across programs.
Develop and oversee standardized practices for resident engagement at intake, after hospitalization, following medical appointments, during care transitions, and at other critical points in a resident’s stay.
Standardize core care coordination functions, including primary care enrollment, pharmacy connections, medication access, hospitalization tracking, specialty referrals, appointment follow-up, and linkage to community-based services.
Develop practical workflows, policies, procedures, documentation standards, tools, and training materials that can be implemented consistently across multiple sites.
Monitor staff adherence to established practices and provide coaching, problem-solving support, and corrective follow-through when expectations are not met.
Partner with site leadership to adapt implementation to site-specific operations while maintaining consistent organization-wide standards.
Support workforce planning, staffing models, role development, onboarding, and training related to case management and care coordination functions.
Carry a focused caseload of residents with particularly complex medical, behavioral health, housing, substance use, safety, or social service needs.
Provide direct, intensive care coordination and case management support when program teams face barriers or need additional expertise.
Attend existing clinical, housing, and program meetings to identify residents who may benefit from complex-case support.
Develop and apply clear, equitable criteria for referral to and discharge from the Director’s complex-case caseload.
Facilitate interdisciplinary case conferences and coordinate action plans among residents, housing staff, clinical teams, external providers, managed care entities, public agencies, and community partners.
Support teams in navigating hospitalizations, referrals, care transitions, benefits, medication access, primary and specialty care, behavioral health services, and community resources.
Coach program teams through complex cases in ways that build their independent problem-solving skills and capacity over time.
Promote continuity of care and ensure that action items, referrals, and follow-up responsibilities are clearly assigned and completed.
Establish and maintain quality assurance and performance improvement processes for case management and care coordination activities.
Review housing, clinical, care coordination, and other reportable metrics to identify service gaps, inequities, operational barriers, and areas of underperformance.
Use data from InfoFlo, HMIS, external reports, and other organizational systems to evaluate resident outcomes and service effectiveness.
Translate findings into defined improvement plans with responsible parties, timelines, measurable goals, and clear follow-through.
Partner with housing, clinical, operations, and program teams to implement improvement strategies and monitor progress between reporting cycles.
Evaluate whether improvement efforts are producing the intended results and revise strategies when needed.
Provide regular updates to organizational leadership on trends, risks, progress, and unresolved barriers.
Foster a culture in which data is used to improve resident care, staff effectiveness, equity, and organizational accountability.
Design, implement, and oversee a standardized discharge process across housing and clinical programs.
Establish clear expectations, roles, timelines, documentation requirements, and accountability for planned and unplanned discharges.
Ensure discharge planning addresses medication access, follow-up appointments, primary and specialty care, pharmacy connections, health records or health resource information, benefits, referrals, transportation, housing or destination planning, and other necessary supports.
Promote early discharge planning whenever possible and support teams in responding effectively when exits occur abruptly.
Develop tools and quality checks to confirm that Cardea teams completed required continuity-of-care steps before or immediately following a resident’s departure.
Review discharge trends and gaps and implement improvements in collaboration with housing, clinical, and program leadership.
Establish a fair, equitable, trauma-informed, and consistently applied framework for developing and managing behavioral contracts or behavioral agreements across sites.
Provide guidance and oversight to program managers and directors on the content, implementation, follow-up, enforcement, documentation, and staff communication associated with behavioral contracts.
Ensure expectations and consequences are clearly communicated to residents and relevant team members and are applied consistently.
Support program managers and clinical leaders when a resident is being considered for an unplanned exit.
Develop a standardized decision-making and documentation framework that considers risk to the resident, risk to the program and community, the nature and severity of the concern, the likelihood of recurrence, reasonable alternatives, accommodations, mitigating factors, and prior interventions.
Facilitate coordinated review of complex exit decisions across housing, clinical, program, and senior leadership.
Promote thoughtful, timely, equitable, and well-documented decisions while supporting resident safety, program safety, continuity of care, and organizational accountability.
Review patterns in behavioral contracts and unplanned exits to identify disparities, recurring system issues, training needs, and opportunities for prevention.
Serve as Cardea’s internal subject matter expert on case management, care coordination, interdisciplinary service models, and complex-case practice.
Collaborate with medical, behavioral health, housing, operations, and program leaders to support integrated and coordinated service delivery.
Maintain a strong understanding of site-specific operations, cultures, strengths, challenges, and opportunities for quality improvement.
Participate in strategic planning related to interim housing services, organizational growth, and the development of scalable service models.
Develop and maintain partnerships with external providers, community organizations, managed care entities, hospitals, pharmacies, and public agencies.
Foster a culture of client-centered, person-centered, trauma-informed, harm-reduction-oriented, and equitable care throughout Cardea programs.
Perform other duties as assigned.