BH Case Manager

Education & Experience

• Master’s degree in Social Work, Counseling, Psychology, Public Health, Nursing, or a related field preferred.
• Three (3) or more years of experience in behavioral health, care management, case management, population health, or integrated care settings.
• Experience serving individuals with serious mental illness (SMI), substance use disorders (SUD), homelessness, chronic medical conditions, and other complex needs.
• Knowledge of CalAIM, Enhanced Care Management (ECM), Community Supports, Medi-Cal managed care, and social determinants of health.
• Demonstrated skills in care coordination, care planning, crisis intervention, motivational interviewing, patient engagement, and multidisciplinary team collaboration.
• Strong knowledge of community resources, referral networks, patient advocacy, and systems of care for vulnerable populations.
• Experience using Electronic Health Records (EHRs), health information systems, data collection, reporting, quality improvement, and program evaluation methodologies.
• Excellent organizational, communication, and relationship-building skills with the ability to manage multiple priorities in a fast-paced environment.
• Bilingual English/Spanish preferred.

Licensure & Certifications

• Active California healthcare or behavioral health license/registration preferred (e.g., ACSW, LCSW, AMFT, LMFT, APCC, LPCC, RN, or equivalent).
• Valid California Driver’s License, reliable transportation, and ability to travel as required.
• CPR/First Aid certification preferred.
• Certified Case Manager (CCM) and/or Motivational Interviewing (MI) training preferred.
• Bilingual English/Spanish preferred.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Manage a diverse caseload of members with serious mental illness (SMI), substance use disorders (SUD), and complex medical, behavioral health, and social service needs while providing comprehensive care management and ongoing member engagement.

• Conduct outreach, assessment, and enrollment activities to engage eligible members in the Enhanced Care Management (ECM) program and support program growth and participation goals.

• Provide evidence-based behavioral health interventions, motivational interviewing, behavioral activation, crisis intervention, safety planning, and therapeutic support to promote member wellness, self-management, and improved health outcomes.

• Develop, implement, and monitor individualized Shared Care Plans that address medical, behavioral health, housing, and social determinant needs while aligning with member goals and provider recommendations.

• Coordinate care across primary care providers, behavioral health professionals, specialists, hospitals, managed care plans, community-based organizations, and social service agencies to ensure integrated, whole-person care.

• Facilitate transitions of care by coordinating hospital admissions, discharges, referrals, follow-up appointments, and community resource connections to ensure continuity of services and reduce barriers to care.

• Educate members and families on chronic medical and behavioral health conditions, treatment options, community resources, and self-management strategies to improve health literacy and patient engagement.

• Lead and participate in multidisciplinary team meetings, case conferences, and care reviews to support collaborative decision-making and achievement of member-centered outcomes.

Maintain current knowledge of community resources, housing services, supportive programs, and referral networks to effectively connect members with appropriate services and supports.

• Provide guidance, mentorship, and clinical support to care team staff in collaboration with ECM leadership to promote best practices, program compliance, and quality service delivery.

• Ensure accurate, timely, and compliant documentation in Electronic Health Records (eClinicalWorks) and other required systems, including care plans, progress notes, assessments, and program-related data.

• Review and audit member charts and documentation to ensure compliance with managed care contracts, regulatory requirements, quality standards, and organizational policies.

• Monitor program performance and key quality metrics, support program evaluation activities, and identify opportunities for process improvement and enhanced member outcomes.

• Collaborate with ECM Registered Nurses, Program Managers, and interdisciplinary teams to integrate care management services into clinical workflows and support operational effectiveness.

• Develop and distribute educational, outreach, and promotional materials that enhance member engagement, staff knowledge, and program awareness.

• Participate in training, meetings, community events, and other organizational initiatives while performing additional duties as assigned to support program and organizational goals.