Lead Care Manager

Are you an organized individual that would like to make a difference in the community? Join Casa de Amparo's Enhanced Care Management program and help promote wellness, recover and independence to those you serve.

GENERAL FUNCTION: The Lead Care Manager (LCM) plays a central role in the Enhanced Care Management (ECM) Program by providing direct services, coordinating interdisciplinary care, and ensuring timely, efficient access to needed health, behavioral health, and social supports. The LCM functions as a core member of the Care Team, overseeing assigned cases, facilitating communication between clients, caregivers, and service providers, and promoting wellness, recovery, independence, resilience, and empowerment. This role ensures clients receive person-centered and culturally responsive services while maximizing benefit from available health and community resources.

MAJOR TASKS:

• Conduct comprehensive assessments addressing physical health, mental health, substance use, oral health, trauma history, social supports, housing, employment/vocational needs, wellness goals, and linkage to community-based services.

• Oversee development, implementation, and ongoing updating of the Individual Care Plan/Health Action Plan in collaboration with the client and care team.

• Provide services where clients live, seek care, or feel most comfortable, including office-based, telehealth, and field-based locations.

• Facilitate connections to needed community resources, support groups, and social service programs.

• With client permission, coordinate and advocate on behalf of the client with healthcare professionals, including primary care providers and specialty care teams.

• Utilize evidence-based practices, including Motivational Interviewing, Harm Reduction approaches, and Trauma-Informed Care principles.

• Collaborate with hospital staff to support transitional care planning and promote continuity of care.

• Conduct outreach and engagement activities—including phone calls, mailed materials, and field visits—to support enrollment and linkage to ECM services.

• Accompany clients to appointments as appropriate.

• Evaluate client progress, monitor outcomes, and update goals as needed.

• Provide mental health promotion and education to support wellness and recovery.

• Arrange transportation as needed to support engagement in healthcare and social services.

• Complete all documentation within established timeframes and according to program standards.

• Participate in weekly staff/team meetings and attend supervision.

• Attend required training, including specialized certifications such as ACEs training.

Qualifications

QUALIFICATIONS:

• High school diploma or GED required.

• At least 3 years of relevant work experience.

• Long-term resident of the community with strong knowledge of local resources.

• Ability to complete required training and ongoing educational requirements.

• Ability to work flexible hours, including some evenings/weekends.

• Experience using EMR/EHR or care management software.

• Strong organizational skills, time management, and ability to manage a personal schedule.

• Ability to prioritize tasks and meet deadlines.

• Ability to work independently within a virtual environment and as part of a multidisciplinary team.

• Excellent oral and written communication skills.

• Demonstrated interpersonal effectiveness and ability to establish trust and build strong relationships.

• Clear professional boundaries with clients and coworkers.

• Demonstrated cultural competency and ability to work with diverse populations.

• Able to perform home visits, field outreach, and accompaniment to appointments as needed.

• Comfortable using computers for documentation, communication, and organizing work.

• Active listening skills, compassion, and sound judgment in the application of professional services.

• Multilingual capabilities preferred but not required.

• Prior experience as a Community Health Worker, Peer Support Specialist, Medical Assistant, or similar role preferred.