Lead Care Manager- CalAIM Services

Friends Outside•Stockton, CA

1d•Remote

About The Position

The Lead Care Manager provides comprehensive, person-centered care coordination to individuals enrolled in Enhanced Care Management (ECM) and Community Supports (CS) services. Working with high need, justice-involved, and/or housing insecure populations, the Care Manager delivers field-based services that address medical, behavioral health, and social determinants of health. This role is responsible for outreach, engagement, assessment, care planning, service linkage, and ongoing support to help members achieve stability, improve health outcomes, and maintain housing.

Requirements

2-year degree in Social Work, Human Services, Sociology or a related field
Certified Community Health Worker or the ability to obtain certification within 12 months of hire
Experience in providing CalAIM programs
Experience in case management, care coordination, or social services, preferably with high-need or justice-involved populations
Knowledge of housing resources, homelessness systems, and community-based services
Familiarity with trauma-informed care, harm reduction, and person-centered practices
Strong organizational, communication, and problem-solving skills
Ability to work independently in community and field-based settings

Nice To Haves

Knowledge of Medi-Cal systems and documentation requirements
Experience using EHR or case management systems
Bilingual English/Spanish

Responsibilities

Conduct proactive, field-based outreach to locate, engage, and build trust with eligible members, including those experiencing homelessness or reentry from incarceration
Perform outreach in a variety of settings, including streets, shelters, correctional facilities, hospitals, and community locations
Educate potential members on ECM and Community Supports services and assist with enrollment
Obtain and document required consents for services and data sharing in compliance with program requirements
Complete comprehensive assessments to identify member needs, strengths, risks, and goals
Develop and implement individualized care plans and/or housing support plans that are person-centered and goal-oriented
Continuously reassess member needs and update care plans based on progress and changing circumstances
Coordinate care across physical health, behavioral health, housing, and social service systems
Connect members to medical providers, behavioral health services, substance use treatment, and community-based resources
Facilitate referrals and warm handoffs to ensure successful service linkage
Advocate on behalf of members to reduce barriers and improve access to services
Conduct housing assessments and assist members in identifying and securing safe and stable housing
Support completion of housing applications, documentation collection, and access to housing resources
Assist with securing housing deposits, utilities, and other one-time needs necessary for move-in
Provide tenancy support, including landlord communication, eviction prevention, and crisis intervention
Educate members on tenant rights, responsibilities, and independent living skills
Maintain regular contact with members based on acuity and service requirements
Provide coaching and support in areas such as budgeting, life skills, and health management
Monitor member progress and adjust interventions as needed
Participate in multidisciplinary team meetings and case consultations
Maintain accurate, timely, and complete documentation in electronic health record (EHR) systems
Document all outreach, assessments, care plans, progress notes, and service activities in accordance with program standards
Ensure compliance with HIPAA, confidentiality, and data-sharing requirements
Support billing and reporting processes by ensuring documentation meets required standards
Work collaboratively with multidisciplinary team members, including clinical consultants and supervisors
Coordinate with Managed Care Plans (MCPs), housing providers, community-based organizations, and other partners
Participate in trainings and maintain knowledge of ECM, Community Supports, and CalAIM requirements
Other duties as assigned