Case Manager (SUD Population Focus)

JOB TITLE: Case Manager (SUD Population Focus)

SUPERVISED BY: Program Director

STATUS: Non-Exempt, Full-Time

Via Care Community Health Center

JOB SUMMARY

The ECM Case Manager provides whole-person, member-centered care management services to Medi-Cal members with complex health and social needs, with a primary focus on individuals impacted by substance use disorders (SUD). Through outreach, engagement, assessment, care planning, coordination, and follow-up, the ECM Case Manager supports members in accessing medical, behavioral health, housing, and community-based services that improve health outcomes and overall well-being.

The ECM Care Manager does not provide substance use counseling, psychotherapy, or clinical treatment services. Instead, the role focuses on care coordination, service linkage, advocacy, and member engagement to help individuals navigate complex systems of care.

ESSENTIAL FUNCTIONS

• Member Engagement and Outreach
• Conduct field-based, community-based, and telephonic outreach to engage ECM-eligible members.
• Establish trusting relationships with members through a trauma-informed and culturally responsive approach.
• Meet members where they are, including homes, shelters, treatment facilities, hospitals, community settings, and other approved locations.
• Maintain ongoing contact with members according to ECM program requirements.
• Assessment and Care Planning
• Complete comprehensive assessments of members' physical health, behavioral health, substance use, housing, social support, and resource needs.
• Develop individualized care plans that reflect member goals, strengths, and priorities.
• Monitor progress toward care plan goals and update plans as needed.
• Identify barriers to healthcare access and engagement.
• Care Coordination
• Coordinate services across medical, behavioral health, social service, and community-based systems.
• Facilitate communication among providers, health plans, community organizations, and support networks.
• Assist members in scheduling and attending appointments.
• Support transitions of care following emergency department visits, hospital admissions, residential treatment episodes, incarceration, or other significant life events.
• Ensure members receive appropriate follow-up services and supports.
• SUD-Focused Care Management
• Support individuals with substance use disorders through engagement, education, advocacy, and resource navigation.
• Coordinate referrals and warm handoffs to substance use treatment and recovery support programs.
• Assist members in accessing medication-assisted treatment (MAT), outpatient treatment programs, residential treatment services, recovery support services, behavioral health services, peer support programs.
• Promote harm reduction and recovery-oriented principles.
• Encourage member participation in services while respecting individual choice and readiness for change.
• Community Supports Coordination
• Assist members in accessing CalAIM Community Supports and other community resources.
• Coordinate housing-related services including housing navigation, tenancy support, and housing stabilization resources when appropriate.
• Support access to transportation, food resources, public benefits, and community-based services.
• Advocate for members within healthcare, housing, and social service systems.
• Documentation and Compliance
• Maintain accurate, timely, and complete documentation in electronic health records and care management systems.
• Document assessments, care plans, member contacts, referrals, and outcomes according to organizational and regulatory requirements.
• Participate in case conferences, interdisciplinary care team meetings, and quality improvement activities.
• Adhere to CalAIM ECM, Medi-Cal Managed Care, HIPAA, and organizational requirements.

QUALIFICATIONS

• Education
• Bachelor's degree in Social Work, Human Services, Psychology, Public Health, Nursing, Health Administration, or related field; OR
• Equivalent education and experience consistent with organizational and ECM program requirements.
• Experience
• At least one (1) year of experience in care management, case management, behavioral health, homeless services, social services, community health, or a related field.
• Experience working with individuals with substance use disorders and knowledge of recovery-oriented and harm-reduction approaches required.
• Experience serving Medi-Cal or other vulnerable populations preferred.
• Knowledge, Skills, and Abilities
• Knowledge of Enhanced Care Management and Community Supports preferred.
• Understanding of substance use disorders, recovery principles, and harm reduction practices.
• Knowledge of community resources, healthcare systems, and social service programs.
• Strong motivational interviewing and engagement skills.
• Ability to work independently in field-based environments.
• Strong organizational, communication, and documentation skills.
• Ability to maintain professional boundaries and confidentiality.
• Commitment to person-centered, trauma-informed, and culturally responsive care.
• Preferred Qualifications
• Experience working in ECM, Health Homes, Whole Person Care, behavioral health, homeless services, or community health programs.
• Community Health Worker (CHW), Certified Case Manager (CCM), or related certification preferred.
• Experience working with Medi-Cal managed care populations.
• Bilingual skills preferred.