Community Health Worker - Lead Care Manager

Position Summary

The Community Health Worker – Lead Care Manager is a trusted community-based advocate who provides direct services, care management, and care coordination through the Enhanced Care Management Program at their assigned Sickle Cell Disease clinic. Under the direction of the CHW Program Managers and Clinic Site Consultant, the LCM manages assigned cases, coordinates healthcare benefits and services, provides education, and helps clients access timely, cost-effective care. The LCM works with clients, caregivers, families, providers, and the interdisciplinary care team to support wellness, recovery, independence, resilience, and empowerment. The LCM also advocates for clients and serves as a liaison to SCDF programs and community health and social service providers.

Community-Based Duties and Responsibilities

• Community Outreach, Engagement, and Direct Client Support: Conduct outreach and engagement by phone, mail, field or home visits, tele-health, and other community-based contacts. Provide services where clients live, receive care, or are easiest to reach. Help clients follow care recommendations and connect with trusted community resources.
• Resource Navigation and Social Support: Connect clients with resources for food, housing, transportation, education, employment, benefits, utilities, family support, and other social needs. Provide warm handoffs, follow up on referrals, and help clients build the skills and confidence to access services independently.
• Health Education and Community Outreach: Provide culturally responsive education to individuals, families, and community groups about Sickle Cell Disease, chronic disease management, preventive care, wellness, available resources, and care navigation. Participate in health fairs, workshops, educational sessions, outreach activities, and SCDF events to increase awareness and access to services.
• Client Empowerment and Self-Management: Help clients understand their health conditions, set wellness goals, prepare appointments, ask questions, communicate needs, and follow care recommendations. Encourage self-advocacy, informed decisions, and confidence in managing health and social service needs.
• Advocacy and Community Collaboration: With client permission, coordinate and advocate for social service agencies, community organizations, caregivers, family support persons, and other partners. Serve as a liaison among clients, programs, providers, and community resources.
• Evidence-Based, Trauma-Informed Practice: Use Motivational Interviewing, Harm Reduction, trauma-informed care, culturally responsive communication, and client-centered engagement to build trust and support empowerment, independence, and resilience.

Clinical-Based Duties and Responsibilities

• Assessment, Care Planning, and Case Management: Use a CHW-centered, relationship-based approach to assess physical health, mental health, substance use, oral health, trauma-related, social support, housing, employment, wellness, and other social needs. Work with clients, caregivers, families, providers, and the interdisciplinary team to develop, carry out, monitor, and update individualized care plans, health action plans, and transition plans. 
• Care Coordination and Health System Navigation: Coordinate medical, behavioral health, dental, social service, and community supports. Help clients navigate healthcare systems, public benefits, managed care plans, referrals, and community resources. Assist with appointments, transportation, referrals, barriers to care, continuity of care, and treatment plan follow-through.
• Sickle Cell Disease and Clinic Support: Support clients in specialized Sickle Cell Disease settings, including Networking California for Sickle Cell Care clinics. Apply advanced resource navigation, patient support, care coordination, and chronic disease support skills to meet the needs of individuals and families affected by SCD.
• Clinical Advocacy and Team Collaboration: With client permission, coordinate and advocate with primary care providers, specialists, hospital staff, caregivers, family support persons, and other providers. Actively participate on the interdisciplinary care team to support timely, coordinated, client-centered care.
• Transitional Care and Special Projects: Work with hospital staff on transition planning and support clients moving between care settings, including pediatric-to-adult care. Lead or participate in special projects and community health initiatives that improve client and family access, coordination, and outcomes.
• Data, Documentation, and Reporting: Complete accurate documentation on time and enter data in real time. Keep client records current, track care-plan progress and caseload outcomes, document outreach and engagement, and meet program reporting requirements in EMR/EHR or care management systems.
• ECM Requirements, Meetings, Supervision, and Training: Complete all documentation within individual action-plan deadlines. Attend weekly staff and team meetings, supervision, assigned training, ACEs certification, and all other required program or organizational training.
• Mentoring and Team Support: Guide and support CHW I team members and assist with onboarding, training, mentoring, and peer learning.
• Other duties as assigned

Knowledge, Skills, and Abilities

• Strong relationship-building, communication, active listening, advocacy, and culturally responsive engagement skills.
• Knowledge of community resources, healthcare navigation, public benefits, social services, referrals, and social drivers of health.
• Ability to manage a caseload, prioritize work, meet deadlines, maintain professional boundaries, and complete documentation accurately and timely.
• Ability to work independently across clinic, office, virtual, field, and community settings while collaborating with interdisciplinary teams.
• Comfort using EMR/EHR systems, care management platforms, computers, and other tools for documentation, scheduling, communication, and reporting.
• Ability to apply core CHW competencies including outreach, resource navigation, health education, informal counseling, advocacy, service coordination, and client empowerment.

Minimum Requirements

• A min of an Associate degree in Social Work, Human & Health Services, Public Health, Healthcare Admin. or a related field OR an equivalent combination of college-level education and five plus years of relevant work experience.
• At least three years of relevant experience in community health work, enhanced care coordination and case management, healthcare navigation, social services, peer support, or a related field.  
• Experience supporting people with chronic health conditions, complex care needs, or social-determinant barriers.
• Long-time community resident or strong working knowledge of local resources and service systems.
• Able to complete assigned training and ongoing education requirements and meet deadlines.  
• Able to work flexible hours, including occasional evenings and weekends, and travel as needed to clinics, hospitals, community locations, and outreach sites.

Preferred Qualifications

• Previous experience as a Community Health Worker, Peer Support Specialist, Lead Care Manager, Case Manager, Care Coordinator, or similar professional.
• Current CHW Certification and willing to complete SCDF CHW Training Program
• At least three years of clinical or community health experience, preferably in chronic disease, Sickle Cell Disease, or complex care.
• Experience providing health education, community outreach, patient advocacy, and resource support to diverse audiences.
• Fluency in Spanish and/or Haitian Creole with ability to translate and interpret.
• Familiarity with Enhanced Care Management, Medi-Cal, managed care plans, CHW Benefit, and Community Supports services.

Working Conditions/Physical Requirements

Work primarily in a climate-controlled environment with minimal safety/health hazard potential. Sedentary, sitting, walking, frequent visual use for reading and computer use.

This job will require regular local travel to assigned clinical site at Hillcrest Medical Center at UC San Diego Health.

Staff who are 75+ Miles from the SCDF Home Office in Ontario, CA will be required to report for quarterly meetings and SCDF Events, as needed.

Travel and Per Diem Expenses Provided

Benefits

• 401(k) and 401(k) matching
• Dental, Vision and Health Insurance
• Paid Time Off 
• Mileage – Travel Reimbursement

Schedule: Hybrid – Variable (In-Clinic / In-Office / Work from Home)

• Monday – Friday with some Saturdays
• 8:00 AM – 5:00 PM

Other Requirements

• Valid CA Driver's License
• Reliable transportation and Auto Insurance 
• Pass Background Check

Equal Opportunity Employer

The Sickle Cell Disease Foundation is an equal opportunity employer committed to diversity and an inclusive workplace.