Serve as the client’s primary point of contact and coordinate with doctors, specialists, pharmacists, social services providers, caregivers, and the Care Team
Manage client cases, coordinate health care benefits, provide education, and facilitate member access to care in a timely and cost-effective manner
Assess member needs in physical health, mental health, SUD, oral health, palliative care, memory care, trauma-informed care, social supports, housing, and referral/linkage to community-based services
Oversee development of client care plans and SMART goal setting
Offer services where the member resides, seeks care, or finds most easily accessible, including office-based, telehealth, or field-based services; travel throughout Sacramento County required
Connect clients to other social services and supports and 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 to facilitate linkage to the ECM program and log activity in the CRM system
Evaluate client progress, update SMART goals, arrange transportation, complete all documentation and outcome measures, maintain EMR and other business systems, and complete monthly reporting to ensure program compliance
Attend training as assigned
Requirements
MSW degree, or 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 or more 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
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
Must have general computer skills and a working knowledge of Google Workspace, MS Office, and the internet
Bilingual (English/Spanish) is a plus
Vaccination requirement: Employees in patient, client, or customer-facing roles must be vaccinated against COVID-19 and influenza (religious/medical accommodations considered)
Compliance with federal law requires identity and work eligibility verification using E-Verify upon hire
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