Job Description

This role works closely with Care Team Operations, Clinical Operations, Behavioral Health clinicians (LMFT/LCSW/LPCC), Community Health Workers (CHWs), Compliance, Finance (for authorizations), Care Operations Associates, and external partners including hospitals, primary care providers, behavioral health agencies, housing providers, and community-based organizations.

Responsibilities

• Serve as the primary point of contact for assigned members with behavioral health and psychosocial complexity, building trust through consistent, trauma-informed engagement.
• Conduct comprehensive, holistic assessments addressing behavioral health, substance use, functional status, social determinants of health, safety risks, and care gaps.
• Develop, implement, and maintain person-centered care plans that integrate behavioral, medical, and social goals; update plans following transitions of care or changes in condition.
• Coordinate services across the continuum of care, including behavioral health providers, primary care, hospitals, housing supports, transportation, social services, and community-based organizations.
• Conduct required in-person home or community visits based on acuity, risk stratification, and payer requirements.
• Support Transitions of Care (TOCs) by completing timely follow-up, coordinating post-discharge services, and reinforcing discharge instructions and medication understanding.
• Utilize motivational interviewing, behavioral coaching, and health education to promote engagement, adherence, self-management, and long-term member stability.
• Identify, escalate, and address behavioral health risks, safety concerns, service delays, benefit lapses, and environmental barriers using HHN escalation protocols.
• Coordinate and track referrals, appointments, transportation, and follow-ups to ensure continuity and timeliness of care.
• Maintain accurate, timely, and audit-ready documentation of all assessments, encounters, and interventions in eClinicalWorks (ECW) and other HHN systems.
• Meet or exceed HHN and health plan productivity standards, including outreach cadence, encounter requirements, documentation timeliness, TOC completion, and quality measures.
• Actively participate in multidisciplinary case reviews, care conferences, team huddles, and escalations with nurses, behavioral health clinicians, CHWs, care operations, and compliance.
• Assist members with plan navigation, eligibility redeterminations, social service applications, housing resources, and crisis intervention support.
• Communicate professionally with members and care partners using HHN-approved channels, including phone, RingCentral, secure messaging, and SMS workflows.
• Contribute to continuous quality improvement efforts by identifying workflow gaps, documenting barriers, and sharing insights to improve care delivery.
• Uphold confidentiality and comply with all HIPAA, Medi-Cal, ECM, and payer regulatory requirements.
• Remain flexible and responsive to member needs, including field-based work and engagement in community settings.

Skills Required

• Bilingual (English/Spanish) proficiency required to support member engagement and care coordination.
• Strong ability to build rapport and trust with diverse, high-need member populations.
• Proficiency in using eClinicalWorks (ECW), Google Suite (Docs, Sheets, Drive), RingCentral, and virtual communication tools.
• Ability to interpret and use PowerBI dashboards, reporting tools, and payer portals.
• Demonstrated skill in conducting holistic assessments and developing person-centered care plans.
• Experience with motivational interviewing, trauma-informed care, or health coaching.
• Strong organizational and time-management skills, with the ability to manage a complex caseload.
• Excellent written and verbal communication skills across in-person, telephonic, and digital channels.
• Ability to work independently, make sound decisions, and escalate appropriately.
• Knowledge of Medi-Cal, SDOH, community resources, and social service navigation.
• High attention to detail and commitment to accurate, audit-ready documentation.
• Ability to remain calm, patient, and professional while supporting members facing instability or crisis.
• Comfortable with field-based work, home visits, and interacting in diverse community environments.
• Cultural humility and demonstrated ability to work effectively across populations with varied lived experiences.

Competencies

• Member Advocacy: Champions member needs with urgency and integrity.
• Operational Effectiveness: Executes workflows consistently and flags process gaps.
• Interpersonal Effectiveness: Builds rapport with diverse populations.
• Collaboration: Works effectively within an interdisciplinary care model.
• Decision Making: Uses judgment to escalate or intervene appropriately.
• Problem Solving: Identifies issues and creates practical, timely solutions.
• Adaptability: Thrives in a fast-growing, startup-style environment with evolving processes.
• Cultural Competence: Engages members with respect for their lived experiences.
• Documentation Excellence: Produces accurate, timely, audit-ready notes every time.
• Strong empathy, cultural competence, and commitment to providing individualized care.
• Ability to work effectively within a multidisciplinary team environment.
• Exceptional interpersonal and communication skills, with a focus on building trust and rapport with diverse populations.

Job Requirements

• Education:
• Bachelor’s degree in Social Work, Psychology, Public Health, Human Services, or related field.
• Licensure:
• Licensed LMFT, LCSW, LPCC.; certification in care coordination or CHW training is a plus.
• Experience:
• 1–3 years of care management or case management experience, preferably with high-need Medi-Cal populations.
• Experience in community-based work, homelessness services, behavioral health, or SUD settings strongly preferred.
• Familiarity with Medi-Cal, ECM, and community resource navigation.
• Travel Requirements:
• Regular travel for in-person home or community visits (up to 45%).
• Physical Requirements:
• Ability to perform home visits, climb stairs, sit/stand for prolonged periods, and lift up to 20 lbs if needed.

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