Case Manager - CalAIM Oakhurst

Job Description

Job Description

About us

RH Community Builders is committed to building strong, vibrant, and inclusive communities. Our

mission is to empower individuals to achieve their full potential by expanding access to safe, affordable

housing, supportive services, and essential community resources.

We believe that everyone deserves a stable place to call home and the opportunity to thrive. Through a

person-centered and equity-driven approach, we work to address social determinants of health and

reduce barriers to housing stability and overall well-being.

RH Community Builders is dedicated to fostering a sense of belonging, promoting social and economic

mobility, and supporting individuals on their path to long-term stability. Through collaboration with local

partners, service providers, and community stakeholders, we strive to create sustainable communities

that are resilient, responsive, and built to support lasting success.

Role Description

Our care model is designed to meet members wherever they are whether in their homes, or in their

community. Case Managers are integral to our mission of providing culturally aligned and accessible

care. They build trust through shared cultural and linguistic backgrounds, improving patient

engagement and access to care.

RH Community Builders is seeking a Case Manager to work directly with members to help them

navigate their health and social needs. Please note that this is a fee-for-service program. You will work

with an assigned panel of members experiencing unmet social needs and complex health conditions.

Responsibilities include educating members on disease prevention and healthy behaviors, coordinating

comprehensive care by scheduling appointments and facilitating follow-ups, and addressing social

determinants of health by connecting members to essential community resources.

Your work will enhance member advocacy and satisfaction while reducing healthcare costs by

preventing unnecessary hospital visits. You will also collect and track important health data to ensure

our care model remains responsive to community needs, promoting health equity and improved

outcomes for our members.

This position reports to the Team Lead Supervisor. You will primarily work within the community, with

in-office, in-person responsibilities.

The Case Manager will contribute in the following ways:

The essential functions include, but are not limited to, the following:

● Provide “hand-holding” services, including accompanying members to initial appointments and

supporting navigation of healthcare, social service systems, appointment coordination,

prescription and pharmacy support, lab coordination, referral follow-up, care plan adherence,

and resource linkage.

● Schedule and complete intake appointments, ensuring all required documentation is accurately

completed.

● Conduct in-person member appointments, follow-ups, and re-engagement outreach attempts.

● Assess for social determinants of health (SDOH) needs and enroll members in appropriate

programs, including care planning, referrals, coaching, and discharge/graduation planning.

● Collaborate with a multidisciplinary care team to contribute to care plans, triage requests, and

address complex member needs.

● Document all member and care team interactions across multiple systems and tools in a timely

and accurate manner.

● Participate in community events to support member engagement and trust-building, including

developing relationships with key stakeholders and community organizations.

● Provide culturally and linguistically appropriate health education and support.

● Assist with enrollment in federal and state programs, appointment scheduling, referrals, and

promoting continuity of care.

● Support individualized goal setting using motivational interviewing techniques.

● Conduct individual social needs assessments.

● Identify and reduce barriers to care, including transportation challenges, health literacy gaps,

and psychosocial barriers.

● Provide ongoing social support by actively listening to member concerns and connecting them

to appropriate resources.

Qualifications

Language/Culture

● Fluency (verbal and written) in English and Spanish.

Education

● High school diploma or GED required (minimum).

Requirements for the Role

● Bachelor’s Degree or equivalent related experience in the social services field

● 1–3 years of healthcare experience or healthcare navigation within the community.

● 2–5 years of community work, advocacy, engagement, or organizing experience.

● Previous experience in related roles (health promotion, project coordination, social research, or

administration).

● Familiarity with Google Workspace (preferred).

● Experience documenting in an EHR system (preferred).

● Training in motivational interviewing (preferred).

Complementary Competencies and Skills

● Comfortable working with multiple computer applications simultaneously and willing to learn new

technologies and systems.

● Strong team player with the ability to build effective working relationships.

● Ability to train and support others.

● Knowledge of local resources to address social determinants of health (preferred).

● Flexible and able to travel to various community locations.

● Willingness to support in-person member appointments.

● Reliable transportation required.