CalAIM ECM Care Coordinator - Bilingual Healthcare Case Manager

Job Description

Job Description

Our Mission:Abrazar (to Embrace in Spanish) is a non-profit, direct-service organization providing services to residents in Orange County. Abrazar is dedicated to embracing the diversity of families in our community, educating them on the resources we provide through our community collaborations, and empowering them to improve the quality of their lives through programs addressing health equity. Abrazar has been addressing inequities in the social drivers of health since 1975.Abrazar serves the community by delivering programs that address the social drivers of health and improve health equity. Our goals are to Embrace, Educate and Empower children, families, and individuals with the necessary tools to achieve better health outcomes. We believe that diversity and the delivery of collaborative services are critical to the success of our programs and measure the impact of our programs by evaluating their ability to enhance our clients' social drivers of health.Position Summary:The Lead Care Manager plays an essential role in supporting Medi-Cal members with complex health and social needs on their path toward improved health, stability, and well-being. Through CalAIM's Enhanced Care Management (ECM) program, this position provides direct care coordination and navigation services, including comprehensive assessment, individualized care planning, service coordination, referral follow-up, and ongoing member support.Guided by a person-centered, trauma-informed, and culturally responsive approach, the Lead Care Manager collaborates with members, providers, health plans, and community organizations to remove barriers to care, strengthen access to services, and promote better health outcomes. This role is ideal for a compassionate and skilled professional who is passionate about health equity, whole-person care, and creating lasting change in the lives of the individuals and families we serve.We welcome applicants who are compassionate, organized, and dedicated to improving the health and well-being of individuals and families with complex needs. Candidates with experience in care management, case management, healthcare navigation, behavioral health, social services, or care coordination are encouraged to apply.Position Responsibilities:As a Lead Care Manager, you will play a critical role in supporting members with complex health and social needs by coordinating care, addressing barriers, and promoting overall well-being. In this role, you will:Provide direct care management and referral services to a caseload of approximately 30 members, including crisis intervention and health education.Conduct comprehensive initial and ongoing assessments to identify needs across medical, behavioral health, substance use, housing, financial, and other social drivers of health.Develop and implement individualized, person-centered care plans in collaboration with members and service providers, in alignment with CalAIM ECM standards.Coordinate care across healthcare providers, behavioral health services, and community-based organizations to ensure seamless, integrated support.Partner with medical professionals to support members managing chronic conditions such as diabetes, asthma, heart disease, hypertension, behavioral health conditions, and HIV.Maintain consistent member engagement through in-person and virtual visits, providing ongoing support and monitoring progress toward care plan goals.Connect members to public benefits, community resources, and supportive services to improve access to care and long-term stability.Accurately document all assessments, care plans, services, and member interactions in compliance with program and funder requirements.RequirementsWe are seeking candidates who are passionate about improving health outcomes and supporting individuals and families with complex medical, behavioral health, and social needs. The ideal candidate will bring strong care management experience, excellent relationship-building skills, and a commitment to serving vulnerable populations with compassion, professionalism, and a whole-person care approach.Successful candidates will:Have knowledge of chronic medical conditions, mental health, substance use, homelessness, and the social drivers of health.Demonstrate strong care management and documentation skills, including assessment, care planning, coordination, and progress monitoring.Apply a person-centered, trauma-informed, and culturally responsive approach when working with members.Coordinate care across physical health, behavioral health, and social service systems to support whole-person care.Have experience navigating healthcare systems, health insurance, and/or public benefits such as Medi-Cal, CalFresh, and CalWORKs.Communicate effectively and build strong relationships with members, providers, and community partners.Engage members through in-person, telephonic, and virtual outreach, including field-based services as needed.Identify and address barriers to care, access, and engagement through problem-solving and advocacy.Be highly organized, detail-oriented, and able to manage multiple priorities in a fast-paced environment.Handle confidential information in accordance with HIPAA and program requirements.Thrive in dynamic environments and adapt to changing priorities and member needs.Work both independently and collaboratively within a multidisciplinary team.Demonstrate a strong commitment to Abrazar's mission and the communities we serve.Be available for occasional evenings, weekends, and rotating on-call or phone coverage as needed.Preferred QualificationsCandidates will stand out if they have:Two to three years of experience in care management, case management, healthcare navigation, or a related field.Training in Motivational Interviewing, Trauma-Informed Care, Crisis Intervention, De-escalation, Harm Reduction, Domestic Violence, Substance Use, or Suicide Prevention.Experience in community outreach, engagement, and partnership development.Experience using electronic health records (EHR) or case management systems; experience with Efforts to Outcomes is a plus.Strong computer skills, including Microsoft Office (Word, Excel, PowerPoint), with intermediate to advanced Excel proficiency.Knowledge of local resources and services available in Orange County.Minimum QualificationsTo be considered for this position, candidates should have:A bachelor's degree in social work, human services, public health, or a related field (preferred).At least one year of experience in case management, healthcare, homeless services, or a similar role serving vulnerable populations.Experience working with individuals with complex health, mental health, or substance use needs.Proficiency with Microsoft Office Suite and electronic documentation systems.Bilingual skills in English and Spanish or English and Vietnamese.Availability to work occasional Saturdays.Mandatory RequirementsAll candidates must be able to meet the following conditions of employment:Authorization to work in the United StatesCPR and First Aid certification, or willingness to obtain certificationSuccessful completion of a TB test, background screening, alcohol and drug testDriving RequirementsDriving is an essential function of this position. Candidates must:Have reliable transportationPossess a valid driver's licenseProvide proof of current auto insurance and vehicle ownership for any personal vehicle used for work dutiesBe able to qualify for coverage under Abrazar's automobile insurance policyPhysical, Mental and Environmental Demands and Conditions: Must be able to sit, stand, and walk frequently, including for extended periods during meetings, trainings, conferences, and community events held in the office or at offsite locations.Must be able to work effectively in a standard office environment and move throughout the workspace to complete daily tasks, including accessing files, supplies, and office equipment.Must be able to communicate clearly, accurately, and professionally in person, by phone, and in virtual settings.Must be able to transport a laptop, files, and other work-related materials to and from meetings and community locations.Must be able to drive to meet with members, providers, and community partners at various locations.Must have sufficient manual dexterity to use a computer, write notes, operate office equipment, complete documentation, and manage files and paperwork.Must have sufficient visual ability to read printed and electronic documents.Must be able to independently analyze information, exercise sound judgment, solve problems, and make appropriate decisions in carrying out job duties.Frequently required to use hands and fingers and to talk and hear.Occasionally required to bend, stoop, kneel, crouch, climb, or balance.Occasionally exposed to outdoor weather conditions and varying temperatures while traveling to off-site locations.The noise level in the work environment is usually moderate.Must be able to occasionally lift and/or move up to 50 pounds.This description reflects management's assignment of essential functions. This job description is subject to change at any time. This description is intended to indicate the kinds of work duties that will be required in this position. It is not intended to limit, or in any way modify, the rights of any supervisor to assign, direct, and contract work of staff under his/her supervision. The use of a particular illustration describing duties shall not be held to exclude other duties, not mentioned, that are of a similar level or difficulty. Diversity in organizational practices is a core value of ABRAZAR resulting in culturally competent services, materials, resources, and programs. Our hiring and business practices appreciate the strengths offered through different backgrounds.About Abrazar (to Embrace)Abrazar (to Embrace) is a 501 (c) 3 non-profit organization that provides shuttle bus and non-emergency medical transportation to patients. Abrazar is dedicated to promoting the general welfare and prosperity of very poor to medium-income seniors and families in Orange County through programs that improve health, nutrition, socialization, lifelong learning and economic self-sufficiency in culturally sensitive waysAbrazar is an Equal Opportunity Employer and does not discriminate on the basis of race, ethnicity, religion, gender, age, physical disability, and sexual orientation. Abrazar complies with all EEO and ADA guidelines.Any offer of employment is contingent upon satisfactory completion of a background check and post-offer, pre-employment screening, which includes drug, alcohol, TB, and job-related physical testing, as permitted by law.