Job Description

Position Summary 

The Case Manager is responsible for providing direct services to clients referred to the CalAIM Enhanced Case Management Program. This position plays a critical role in coordinating care among multiple providers and addressing clients’ medical, behavioral, and social service needs. The Case Manager creates individualized care plans that meet health plan requirements and address barriers to care, including providing health education and coaching to promote long-term self-sufficiency.

The Case Manager also serves as the primary point of contact for a client’s care team, which may include primary care providers, behavioral health professionals, housing support services, SUD providers, and natural supports. If a client is dually enrolled in CalAIM Community Supports, the Case Manager may also provide Housing Navigation or Housing Tenancy services as needed.

Essential Duties and Responsibilities

The essential functions include, but are not limited to the following:

• Serve as the Case Management Case Manager for assigned clients

• Maintain accurate and timely documentation and client records in compliance with program requirements

• Provide "hand-holding" services, including accompanying clients to initial appointments and helping them navigate health systems

• Deliver psychoeducation and teach clients the importance of addressing medical needs proactively

• Educate clients on how to attend and prepare for regular medical appointmentsProvide guidance on how untreated or unmanaged medical conditions may worsen over time

• Act as a liaison among all of the client’s providers, ensuring coordinated and integrated service delivery

• Advocate for the client’s needs while promoting client voice and choice in all aspects of care

• Support clients in accessing essential needs, such as food, transportation, housing, and public benefits

• Help clients develop daily living skills and long-term self-sufficiency

• Identify and reduce barriers to care, including transportation, health literacy, or psychosocial challenges

• Participate in multidisciplinary team meetings and collaborate with community partners

Minimum Qualifications (Knowledge, Skills, and Abilities)

• Minimum of 2 years of experience in case management, care coordination, or a related social services role

• Knowledge of the Fresno Madera Continuum of Care and Housing Services

• Strong knowledge of medical terminology and chronic health conditions

• LVN (Licensed Vocational Nurse) certification highly recommended

• Prior experience working with individuals experiencing homelessness, serious mental illness, substance use disorder, or complex physical health conditions preferred

• Familiarity with Medi-Cal, CalAIM, or managed care systems is a plus

• Demonstrated ability to provide compassionate, client-centered care and health education

• Excellent interpersonal, organizational, and written communication skills

• Proficient in documentation and case noting in electronic systems

• Clean driving record

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