Serve as the client’s primary point of contact and coordinate with providers (doctors, specialists, pharmacists, social services, etc.)
Manage client cases, coordinate health care benefits, provide education, and facilitate member access to care in a timely and cost-effective manner
Collaborate and communicate with caregivers/family support persons and Care Team to promote wellness, recovery, independence, resilience, and member empowerment
Assess member needs across physical health, mental health, SUD, oral health, palliative care, memory care, trauma-informed care, social supports, housing, and community-based services
Oversee development of client care plans and SMART goal setting and evaluate client progress
Offer services where the member resides or finds most accessible (office-based, telehealth, field-based)
Connect clients to social services and supports and arrange transportation (e.g., ACCESS)
Advocate on behalf of the client with health care professionals
Utilize evidence-based practices such as Motivational Interviewing, Harm Reduction, and Trauma-Informed Care principles
Conduct outreach and engagement activities and log activity in CRM
Maintain up-to-date patient health records in EMR and other business systems, complete documentation and outcome measures timely
Complete monthly reporting to ensure program compliance and attend assigned training
Requirements
MSW degree, or active ACSW, LCSW, or LMFT license in California required
1+ year of experience as a care manager, care navigator, or community health worker supporting vulnerable populations (2+ years preferred)
Willing and able to work Monday-Friday 8:30am-5:00pm, both in the field and remotely, with flexibility for potential evenings and weekends
Willing and able to travel throughout the assigned territory (Los Angeles County)
Working knowledge of government and community resources related to social determinants of health
Excellent oral and written communication skills
Positive interpersonal skills
Clean driving record, valid driver's license, and reliable transportation
General computer skills and working knowledge of Google Workspace, MS Office, and the internet
Experience with Electronic Medical Record (EMR) systems and Client Relationship Management (CRM) systems
Bilingual (English/Spanish) is a plus
Compliance with background screening, drug/health screenings, vaccination requirements, and E-Verify work eligibility verification
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