Care Manager I / Lead Care Manager I (JCM)

Duties And Responsibilities

• Conduct community-based outreach and engagement to identify, locate, and enroll eligible justice-involved individuals.
• Support participants transitioning from incarceration and other institutional settings, including coordinating pre-release planning, warm handoffs with jail-based and CDCR care managers, and immediate post-release connection to services.
• Perform holistic, person-centered comprehensive assessments to identify participants' physical health, behavioral health, social service, and other support needs.
• Develop, implement, and regularly update individualized Care Management Plans with SMART goals in collaboration with each participant.
• Serve as the single point of contact for participants, coordinating care across medical, behavioral health, social service, correctional systems, and Medi-Cal Managed Care Plans (MCPs).
• Provide field-based services, accompany participants to critical appointments, coordinate transportation, and deliver hands-on support to ensure timely access to needed services.
• Advocate for participants and assist them in navigating complex service systems.
• Connect participants to community resources addressing Social Determinants of Health (SDOH), including housing, employment, benefits enrollment, legal assistance, and transportation.
• Educate and empower participants, family members, and natural supports to actively participate in care planning and self-management.
• Manage a caseload of up to 30 participants, maintain a minimum of four (4) hours of care management contact per participant per month including at least one face-to-face visit every two weeks, and monitor progress toward care plan goals.
• Maintain accurate and timely documentation of all services, referrals, and case notes in the JCOD Care Management System (CMS) and ACE internal EHR system.
• Ensure compliance with HIPAA, program requirements, agency policies, and documentation standards.
• Participate in multidisciplinary team meetings, case conferences, mandatory trainings, bi-weekly County check-ins, Quarterly Learning Communities, and quality improvement activities.
• Perform other duties as assigned.

Knowledge, Skills, And Abilities

• Knowledge of intensive care management principles including person-centered, trauma-informed, strength-based, harm reduction, and restorative justice approaches.
• Knowledge of the justice system, reentry challenges, and the unique needs of justice-involved individuals during community reintegration.
• Knowledge of Social Determinants of Health (SDOH), Medi-Cal/ECM eligibility, Managed Care Plan (MCP) requirements, and community-based resources.
• Ability to conduct comprehensive assessments, develop individualized care plans, and coordinate services across medical, behavioral health, housing, and social service systems.
• Ability to build trusting relationships with justice-involved individuals using motivational interviewing, harm reduction, and other evidence-based engagement approaches.
• Ability to deliver culturally responsive, participant-centered, and equity-focused services that reflect participants' backgrounds and lived experiences.
• Ability to work independently in community-based settings while maintaining effective communication with multidisciplinary teams.
• Strong advocacy, problem-solving, organizational, and case management skills with the ability to respond promptly to urgent and court-ordered referrals.
• Excellent verbal, written, interpersonal, and documentation skills; bilingual ability may be beneficial.
• Proficiency in electronic case management systems, Microsoft Office Suite, and other technology platforms.
• Ability to maintain confidentiality and comply with HIPAA and applicable privacy laws.

Physical Requirements

• Ability to work in office, community, healthcare, correctional, and residential settings.
• Ability to sit, stand, walk, bend, and lift up to 15 pounds.
• Ability to maintain accurate and timely documentation using electronic case management systems.

Qualifications

• Experience as a Community Health Worker (CHW) or Peer Support Specialist (PSS) required; PSS applicants must hold or be eligible for certification through the California Mental Health Services Authority (CalMHSA).
• Minimum two (2) years of experience providing intensive case management, care coordination, reentry services, or related human services to justice-involved, reentry, or underserved populations.
• Experience working with individuals with complex needs, including co-occurring behavioral health conditions, chronic physical health conditions, housing instability, and involvement in multiple service systems.
• Lived experience with incarceration and/or justice system involvement is highly valued and consistent with the program model.
• Bilingual English/Spanish preferred.
• Must not appear on any applicable Provider Exclusion Lists (for ECM service delivery), including the Medi-Cal List of Suspended and Ineligible Providers and the DHHS OIG exclusion list.
• Valid California Driver's License, proof of automobile insurance, reliable transportation, and ability to travel throughout Los Angeles County.
• Successful completion of required background clearance and TB screening.

The anticipated pay range for candidates who will work in California is $28.85 to $30.45 hourly.