Job Summary: The Care Manager is responsible for engaging members telephonically to assess health-related social needs, coordinating referrals, navigating services, tracking outcomes, and ensuring completion of care plans and community-based interventions. 

The ideal candidate is patient-centered, empathetic, and highly organized, with experience supporting Medicaid populations and addressing social determinants of health.

Key Responsibilities

Member Screening & Needs Assessment

• Conduct outbound phone outreach to members to assess social determinants of health, including housing instability, food insecurity, transportation barriers, and access to healthcare services.
• Complete comprehensive social needs assessments and identify gaps in care or unmet community resource needs.
• Build rapport with members and caregivers to understand their individual circumstances, goals, and barriers to achieving improved health outcomes.
• Prioritize members based on acuity, risk factors, and identified social needs.

Care Coordination & Follow-Up

• Develop and implement individualized care plans based on member needs and assessment findings.
• Coordinate referrals to community-based organizations, healthcare providers, and social service agencies.
• Conduct proactive follow-up outreach via phone, text, or digital platforms to ensure members are connected to recommended services.
• Identify and address barriers to care, including transportation, financial challenges, language barriers, or access issues.

Referral Management

• Manage and track referrals to ensure services are received and documented.
• Monitor referral status and confirm completion of services through established workflows.
• Follow up with community partners, providers, and service organizations to verify outcomes and member engagement.
• Escalate unresolved referrals or service delays according to established protocols.

Member Engagement & Education

• Educate members and caregivers on available healthcare and community resources.
• Support members in navigating healthcare systems, social service programs, and community-based supports.
• Utilize motivational interviewing techniques and culturally competent communication to encourage engagement and self-advocacy.
• Promote adherence to care plans and recommended services.

Documentation & Data Management

• Accurately document all member interactions, assessments, referrals, and outcomes within the electronic health record (EHR) or care management platform.
• Maintain compliance with HIPAA, organizational policies, and regulatory requirements.
• Track key performance indicators, including referral completion rates, care gaps closed, and member engagement metrics.
• Ensure timely and accurate reporting of referral outcomes and intervention activities.

Collaboration & Quality Improvement

• Collaborate closely with interdisciplinary teams, including care managers, social workers, nurses, providers, and community partners.
• Participate in case reviews, team meetings, and quality improvement initiatives.
• Identify trends and opportunities to improve referral workflows, member engagement, and overall care coordination effectiveness.
• Support organizational efforts to improve health outcomes and address social determinants of health across the member population.

Required Skills:

• Experience working with Medicaid populations
• Care Management Experience
• Strong technology systems
• Tech saavy
• Must have a quiet, closed off work space with zero distractions
• Must have an ethernet cord and strong internet connection
• Ability to multitask

Preferred Skills:

• Bilingual (any language)
• Multiple monitors
• A headset is strongly preferred
• Health Home Care Management Experience (strongly preferred)

Schedule/Shift:

M-F: 9am - 5:30pm EST (40 hours)

Selling Points:

• Connecting underserved members to day to day necessities
• Remote work setting
• Be apart of a growing organization and program giving back to the community

^*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).

^*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.