Case Manager

JOB SUMMARY


The Case Manager provides direct, trauma-informed case management services to individuals experiencing homelessness and to patients enrolled in Recuperative Care (also known as Medical Respite) programs. This role serves as a critical bridge between acute medical care, behavioral health care, housing stability, and community-based support services, guiding clients through complex systems with compassion and advocacy.


In addition to demonstrating professionalism and reliability, the ideal candidate brings a working knowledge of local community resources, a foundational understanding of medical and behavioral health terminology, and care settings, and a basic familiarity with Medi-Cal insurance and eligibility processes.


KEY RESPONSIBILITIES


Case Management & Client Services

• Conduct comprehensive intake assessments to identify clients' housing, medical, behavioral health, social, and basic needs.

• Develop individualized service plans with measurable goals in collaboration with clients, clinical staff, and partner agencies.

• Provide regular case management check-ins, adjusting service plans as client needs evolve.

• Facilitate coordination of care for clients with existing service providers, including prompt and reliable communication with outside agencies and service providers.

• Maintain accurate, timely case notes and documentation in the agency's case management information system (HMIS or equivalent).
• Coordinate safe discharge planning for Recuperative Care patients transitioning back to community settings, including ensuring continuity of care upon discharge.

• Have a working knowledge of and maintain an up-to-date database of local resources, including but not limited to housing programs, basic needs services, behavioral health providers, domestic violence support, legal services, employment/vocational programs, transportation services, etc.

• Build and maintain referral relationships with community partners to facilitate continuity of care.

• Connect clients to benefits they are entitled to, including SSI/SSDI, CalFresh, and CalWORKs.

• Understand and communicate basic medical information relevant to client care, including common diagnoses seen in the unhoused population (e.g., wound care needs, diabetes management, post-surgical recovery).

• Understand and communicate basic behavioral health information relevant to client care, including common diagnoses seen in the unhoused population (e.g., substance use withdrawal management, commonly misused substances, brief behavioral health intervention techniques, common mental health disorders, coping skills development).

• Accurately document observations and behaviors using appropriate medical and behavioral health terminology, communicating to nursing, clinical, and support staff in a timely manner.

• Monitor client adherence to prescribed treatment plans, medication schedules, and engagement in care, reporting concerns to clinical supervisors.

• Bachelor's degree in social work, Psychology, Public Health, Human Services, or a related field - OR - equivalent combination of education and relevant work experience.

• Minimum 1-2 years of case management or social services experience, preferably in homeless services, recuperative/medical respite care, or a similar setting.

• Demonstrated knowledge of local community resources and social service systems.

• Ability to work effectively with individuals experiencing homelessness, mental illness, substance use disorders, and complex medical conditions.

• Proficiency in basic computer applications and electronic case management systems. Valid driver's license and reliable transportation (if required for client transport duties).

• Experience in a medical respite, skilled nursing, hospital, or clinic settings.

• Familiarity with Medi-Cal/Medicaid systems, managed care plans, and/or benefits enrollment.

• Bilingual or multilingual skills (Spanish strongly preferred).

• Certification in Mental Health First Aid, CPR/First Aid, or Motivational Interviewing.

• HMIS or comparable database experience.

• Trauma-Informed Practice - Demonstrates sensitivity to trauma histories; maintains professional boundaries while building trust.

• Cultural Humility - Provides equitable, inclusive services across diverse populations.

• Communication - Communicates clearly in writing and verbally with clients, clinical staff, and partner agencies.

• Problem-Solving - Approaches complex barriers with creativity and persistence.

• Organization & Time Management - Manages a caseload of multiple clients with competing needs and deadlines.