Case Manager - EPOCH

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 provide coordinated, accessible, and member-centered services that

address both healthcare and social needs. For members residing in Respite Care, timely coordination,

hands-on navigation, and consistent case management are essential to supporting stabilization,

reducing barriers to care, and preparing members for a successful transition back into the community.

RH Community Builders is seeking a Case Manager to serve in a dual role providing both case

management and navigation services to members actively residing onsite in the Respite Care program.

The assigned Case Manager will maintain responsibility for an assigned caseload of Respite Care

members and will serve as a primary point of coordination for their healthcare, social service, benefits,

resource, and discharge-planning needs throughout their stay.

This is a highly hands-on position. In addition to completing assessments, developing service goals,

coordinating care, and maintaining required documentation, the Case Manager will actively assist

members in completing the steps necessary to access services. This may include scheduling

appointments, coordinating transportation, accompanying members to appointments when appropriate,

following up on referrals, assisting with benefits and identification documents, communicating with

healthcare and community providers, and helping members overcome barriers that could delay

services or discharge.

The Case Manager will work closely with the onsite medical team, program leadership, community

providers, health plans, hospitals, social service agencies, and other members of the multidisciplinary

care team to ensure services are coordinated and responsive to each member's identified needs.

Because members are residing onsite, the Case Manager is expected to maintain consistent face-to-

face engagement with assigned members, remain knowledgeable regarding the status of each

member's care and service needs, and proactively address barriers throughout the member's Respite

Care stay.

The Case Manager will contribute in the following ways:

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

● Maintain an assigned caseload of members residing onsite in Respite Care and provide both

case management and hands-on navigation services throughout each member’s stay.

● Complete required intakes, assessments, Housing Plans, and other program documentation

within established timelines.

● Understand and support members in navigating the community’s Coordinated Entry System

(CES), including completing required steps to support housing access and placement.

● Complete required HMIS and CES trainings and maintain the knowledge and system access

necessary to accurately enter and manage member data.

● Complete and maintain competency in community-required assessments, including CESMATs,

and ensure assessments are completed and updated within required timelines.

● Collect, enter, and maintain required program data, including housing placements, case notes,

services, assessments, and member updates within the program’s HMIS project, CES HMIS

project, and any other funder-required systems.

● Conduct regular face-to-face engagement with assigned members to assess needs, establish

goals, monitor progress, and identify barriers to care, housing, and successful discharge.

● Assess and address member needs related to healthcare, behavioral health, housing, benefits,

transportation, and other social determinants of health (SDOH) through appropriate referrals,

coordination, and follow-up.

● Provide hands-on navigation, including scheduling appointments, coordinating transportation,

completing and following up on referrals, assisting with benefits and identification documents,

and connecting members to community resources.

● Coordinate with the onsite medical team, healthcare providers, health plans, housing providers,

community agencies, and other partners to support continuity of care, housing stability, and

timely service delivery.

● Begin housing and discharge planning upon admission, proactively identifying barriers and

coordinating housing resources, aftercare services, and warm handoffs prior to discharge.

● Maintain accurate, timely, and HIPAA-compliant documentation in electronic health records,

HMIS, case files, and other required systems.

● Participate in multidisciplinary case reviews and care coordination, communicating significant

changes, outstanding needs, and barriers that may impact the member’s care, housing, or

discharge plan.

● Provide all services using a member-centered, trauma-informed, and culturally responsive

approach while maintaining confidentiality, professional boundaries, and compliance with

program and funder requirements.

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. (preferred).

● 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).

● Willingness to support in-person member appointments.

● Reliable transportation required.