Reentry Care Manager: Community Health & Transition

Empowering Wellness, Transforming Lives Optima Medical Management Group is dedicated to enhancing the quality of life by promoting wellness. At Optima MMG and all of its divisions: Serene Health, Community Support, and American TrueCare, our mission is to provide comprehensive support and care that not only addresses immediate concerns but also fosters long-term well-being. Empowering Wellness, Transforming Lives Optima Medical Management Group is dedicated to enhancing the quality of life by promoting wellness. At Optima MMG and all of its divisions: Serene Health, Community Support, and American TrueCare, our mission is to provide comprehensive support and care that not only addresses immediate concerns but also fosters long-term well-being. As pioneers in the field, we aspire to lead in member care outcomes and set new standards for excellence and innovation. We are committed to empowering our members to achieve self-sufficiency in health, creating a ripple effect that strengthens families and communities. Our work culture at Optima MMG is built on pride, passion, and a collective commitment to making a positive difference in people's lives. Our team members are dedicated problem-solvers who bring their unique skills and perspectives to the table. We believe that by fostering a collaborative and supportive environment, we can unlock the full potential of our team and, in turn, provide the best possible care to our members. A career at Optima MMG is an opportunity to be part of a dynamic and forward-thinking organization. We encourage continuous learning and professional growth, providing our employees with access to industry experts, cutting-edge technologies, and a supportive community that values each individual's contributions. Join us on this journey to not only advance your career but to be a driving force in transforming lives and communities through passionate and fulfilling work! Job Summary: The official job title is Justice-Involved Lead Care Manager (LCM). The Justice-Involved Lead Care Manager provides comprehensive care management and community-based support services to individuals transitioning from incarceration or involvement with the criminal justice system in accordance with California DHCS CalAIM Enhanced Care Management (ECM) guidelines. The LCM develops individualized care plans, coordinates medical, behavioral health, substance use disorder, and social services, and collaborates closely with members, families, healthcare providers, correctional systems, and community organizations to ensure continuity of care and successful community reintegration. The LCM supports members with complex medical, behavioral health, housing, and social determinants of health needs through field-based outreach, advocacy, care coordination, and ongoing member engagement. Candidates with experience working with justice-involved populations, behavioral health, homelessness services, reentry programs, or substance use treatment are strongly preferred. Lived experience is valued when combined with the ability to maintain professionalism, boundaries, and essential job responsibilities. Responsibilities: Conduct field-based, telephonic, facility-based, and community outreach to primarily justice-involved members transitioning from incarceration. Complete comprehensive assessments to identify medical, behavioral health, substance use, and social determinants of health needs. Develop, implement, and maintain individualized Care Management Plans in accordance with DHCS ECM requirements. Coordinate physical health, behavioral health, substance use treatment, housing, transportation, and community support services. Collaborate with interdisciplinary care teams, healthcare providers, correctional facilities, probation/parole departments, and community-based organizations. Assist members with successful community reintegration, linkage to healthcare services, benefits enrollment, medication continuity, and housing stabilization. Support members in reducing avoidable emergency department utilization and barriers to long-term health stability. Maintain ongoing contact with members through in-person visits, telehealth, phone outreach, and community engagement. Advocate for members and assist with scheduling appointments, accessing treatment, and overcoming healthcare and social barriers. Maintain accurate, timely, and compliant documentation in accordance with DHCS, Medi-Cal, HIPAA, and organizational standards. Provide trauma-informed, culturally responsive, and member-centered care to diverse populations. Maintain professionalism, empathy, and ethical conduct while interacting with members, families, providers, and community partners. Participate in trainings, case conferences, supervision, audits, and quality improvement initiatives. Perform additional duties as assigned. Populations of Focus: Individuals transitioning from incarceration or correctional settings within the past 12 months will be the priority population of focus. Individuals experiencing homelessness or housing instability. Individuals with serious mental illness and/or substance use disorders. Individuals at risk for avoidable hospital or emergency department utilization. Adults living in the community and at risk for long-term care institutionalization. Children and youth involved in child welfare or juvenile justice systems. Individuals with intellectual and/or developmental disabilities who qualify under ECM populations of focus. Pregnant and postpartum individuals experiencing health disparities or qualifying under ECM populations of focus. Education and Experience: High school diploma or GED required. Associate degree or higher in social work, psychology, healthcare, criminal justice, human services, or related field preferred. Minimum of one (1) year of experience in case management, care coordination, behavioral health, healthcare outreach, reentry services, or related field required. Experience working with justice-involved populations strongly preferred. Experience with Medi-Cal, CalAIM, ECM, behavioral health, homelessness services, or substance use treatment preferred. Valid California driver’s license, reliable transportation, and current automobile insurance required. Required Skills/Abilities: Excellent communication, interpersonal, customer service, and organizational skills. Ability to engage vulnerable and hard-to-reach populations using trauma-informed and culturally responsive approaches. Comfortable conducting in-person visits with members in correctional settings to support engagement and care coordination. Strong documentation, computer, email, and electronic health record skills. Ability to work independently and collaboratively within multidisciplinary teams. Strong problem-solving, critical thinking, and resource coordination skills. Ability to manage multiple members and priorities in a fast-paced environment. Knowledge of community resources, behavioral health systems, and social service programs preferred. Physical Requirements: Must be able to travel using personal vehicle to complete outreach visits and community-based member support. Mileage reimbursement provided at the IRS standard rate. Prolonged periods of sitting, standing, driving, and computer use. Ability to occasionally lift up to 15 pounds. Pay range: $25 USD - $30 USD Benefits Our full-time employees are eligible for the following benefits enrollment after 60 days of employment: Medical, Dental, & Vision Benefits: We have various insurance options for you and your family. Short & Long-Term Disability Benefits: Protection when you need it most. Voluntary Accident, Voluntary Critical Illness, and Voluntary Hospital Indemnity Plans: Added security for you and your loved ones. Flexible Spending Accounts: Manage your finances with flexibility. Employee Assistance Program (EAP): Support when life throws challenges your way. 401(K): Building your financial future with us. Effective after 1 year of employment. Paid Vacation and Sick Leave: Flexibility for the planned and unplanned. Paid Holidays: Quality time to enjoy celebrations. Employee Referral Program: Share the opportunities and reap the rewards. Company Discount Program: Enjoy savings on everyday expenses and memberships. Equal Employment Opportunity Optima Medical Management Group and its divisions are an Equal Opportunity Employer. Optima MMG is committed to providing employment opportunities for all qualified candidates without discrimination on the basis of race, religion, sex, sexual orientation, gender identity, age, national origin, citizenship, disability, marital status, veteran status, or any other characteristic protected by federal, state or local laws. Optima MMG is committed to providing reasonable accommodation for individuals with disabilities. Pre-Employment Optima Medical Management Group is a drug-free workplace. Employment is contingent upon a successful pre-employment drug screening and background check. #J-18808-Ljbffr Serene Health