Serve as the client’s primary point of contact and coordinate with providers, caregivers, and care teams under direction of Director of Enhanced Care Management/ECM Clinical Manager/ECM Program Manager
Assess member needs in physical health, mental health, SUD, oral health, palliative care, memory care, trauma-informed care, social supports, housing, and community-based services
Oversee development of client care plans and SMART goal setting; evaluate progress and update goals
Offer services where the member resides, seeks care, or finds most accessible, including office-based, telehealth, or field-based services
Connect clients to social services and supports and arrange transportation (e.g., ACCESS)
Advocate on behalf of clients with health care professionals
Utilize evidence-based practices such as Motivational Interviewing, Harm Reduction, and Trauma-Informed Care principles
Conduct outreach and engagement activities and log activity in the CRM system
Complete all documentation and outcome measures within established timeframes; maintain up-to-date records in the EMR and other business systems
Complete monthly reporting to ensure program compliance and attend assigned training
Requirements
Willing and able to work Monday-Friday 8:30am-5:00pm Pacific Time, with the possibility of afternoons, evenings, and/or Saturday mornings
2+ years experience as a care manager, care navigator, or community health worker supporting vulnerable populations
Experience working in a remote setting (minimum 1 year)
Working knowledge of government and community resources related to social determinants of health
Excellent oral and written communication skills
Positive interpersonal skills
General computer skills and working knowledge of Google Workspace, MS Office and the internet
Bilingual (English/Spanish) is a plus
Legally authorized to work in the United States (will be asked about visa sponsorship)
Willingness to undergo background screening, which may include a drug test or other health screenings
Vaccination requirement for patient, client, or customer-facing roles (COVID-19 and influenza)