Justice Involved Lead Care Manager

Job Summary

The official job title is Justice-Involved Lead Care Manager (LCM). The Justice-Involved Lead Care Manager provides comprehensive care management and community-based support services to individuals transitioning from incarceration or involvement with the criminal justice system in accordance with California DHCS CalAIM Enhanced Care Management (ECM) guidelines.

Responsibilities

• Conduct field-based, telephonic, facility-based, and community outreach to primarily justice-involved members transitioning from incarceration.
• Complete comprehensive assessments to identify medical, behavioral health, substance use, and social determinants of health needs.
• Develop, implement, and maintain individualized Care Management Plans in accordance with DHCS ECM requirements.
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  • Coordinate physical health, behavioral health, substance use treatment, housing, transportation, and community support services.
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    • Collaborate with interdisciplinary care teams, healthcare providers, correctional facilities, probation/parole departments, and community-based organizations.
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      • Aid members in successful community reintegration, linkage to healthcare services, benefits enrollment, medication continuity, and housing stabilization.
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        • Support members in reducing avoidable emergency department utilization and barriers to long-term health stability.
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          • Maintain ongoing contact with members through in-person visits, telehealth, phone outreach, and community engagement.
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            • Advocate for members and assist with scheduling appointments, accessing treatment, and overcoming healthcare and social barriers.
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              • Maintain accurate, timely, and compliant documentation in accordance with DHCS, Medi-Cal, HIPAA, and organizational standards.
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                • Provide trauma-informed, culturally responsive, and member-centered care to diverse populations.
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                  • Maintain professionalism, empathy, and ethical conduct while interacting with members, families, providers, and community partners.
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                    • Participate in trainings, case conferences, supervision, audits, and quality improvement initiatives.