Serve as the client’s primary point of contact and coordinate care with doctors, specialists, pharmacists, social services providers, and others
Assess member needs across 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 goal setting; evaluate progress and update SMART goals
Offer services where the member resides, seeks care, or finds most accessible (office-based, telehealth, or field-based)
Conduct outreach and engagement activities to facilitate linkage to the ECM program and log activity in the CRM system
Advocate on behalf of clients with health care professionals and connect clients to social services and supports
Utilize evidence-based practices such as Motivational Interviewing, Harm Reduction, and Trauma-Informed Care principles
Arrange transportation and manage referrals
Complete all documentation and maintain up-to-date patient health records in the EMR and other business systems
Complete monthly reporting to ensure program compliance and attend assigned training
Requirements
Active California Licensed Vocational Nurse (LVN) license required
Willing and able to work Monday-Friday 8:30am-5:00pm, both in the field and remotely
2+ years of experience as a care manager, care navigator, or community health worker supporting vulnerable populations
Working knowledge of government and community resources related to social determinants of health
Excellent oral and written communication skills
Positive interpersonal skills
Clean driving record, valid driver's license, and reliable transportation
General computer skills and working knowledge of Google Workspace, MS Office, and the internet
Bilingual (English/Spanish) is a plus
Willing and able to travel throughout the Los Angeles County area
Must be legally authorized to work in the United States (E-Verify upon hire)
Background check (which may include a drug test or other health screenings) required prior to employment
Vaccination requirement: employees in patient, client, or customer-facing roles must be vaccinated against COVID-19 and influenza (requests for religious or medical accommodations will be considered)