CICM Case Manager - Santa Clara County

Qualifications

• Minimum of two years’ experience in case management, community outreach, social services, behavioral health support, or similar member-facing work.
• Bachelor’s Degree in Health Care or related field preferred.
• Experience working with individuals experiencing homelessness, medical complexity, behavioral health needs, or social barriers.
• Experience with Medicare/DSNP, Medi-Cal or safety-net healthcare environments preferred.
• Strong interpersonal skills and ability to build trust with diverse populations.
• Knowledge of community resources, housing programs, social supports, and care coordination practices.
• Able to work independently, prioritize responsibilities, and maintain boundaries.
• Strong written and verbal communication skills.
• Proficient with EMR systems.
• Bilingual in Spanish (preferred).

Essential Duties And Responsibilities

• Conduct outreach and engagement activities to connect eligible members with services.
• Perform comprehensive assessments capturing member needs related to medical care, behavioral health, housing, transportation, benefits, and social determinants of health.
• Develop person-centered care plans with member input that reflect goals, strengths, barriers, and service coordination needs.
• Provide ongoing care coordination, warm hand-offs, education, and advocacy to support member progress.
• Facilitate communication among member support systems, including healthcare providers, social service agencies, health plans, behavioral health, and housing programs.
• Conduct field-based activities, including home visits, office visits, and community outreach.
• Use motivational interviewing, trauma-informed care, and culturally responsive approaches to engage members with varying levels of readiness.
• Assist members in accessing transportation, scheduling appointments, applying for benefits, and connecting with appropriate programs or services.
• Support transition activities such as hospital discharge coordination, navigating new providers, or connecting to long-term supports.
• Maintain timely and accurate documentation in accordance with internal and external programmatic standards.
• Track member progress toward goals through case notes, care plan updates, and authorized service logs.
• Meet required engagement, visit, and contact frequency benchmarks based on acuity and program guidelines.
• A significant amount of driving is required.
• Perform other duties as assigned.