Lead Care Navigator

Primary Responsibilities

• Conduct proactive, culturally responsive outreach to identify and enroll eligible pregnant and postpartum individuals into the Birth Equity program.
• Build trust with clients, families, and community partners through respectful, strengths-based engagement.
• Represent the program professionally in community meetings, cross-sector collaboratives, and outreach events.
• Share information and resources across internal programs to support integrated care and coordinated service delivery.
• Contribute to program visibility and outreach through approved communication activities, including community storytelling and social media.

Whole-Person Care Management

• Verify client eligibility and ensure accurate documentation in compliance with Medi-Cal and program requirements.
• Conduct comprehensive assessments through home visits and telehealth sessions, addressing medical, behavioral health, social, and emotional needs.
• Develop, implement, and regularly update individualized care plans that include screenings, risk assessments, referrals, and measurable goals.
• Provide health education, emotional support, and coaching to empower clients during pregnancy and postpartum periods.
• Carefully coordinate referrals and follow-up for healthcare, behavioral health, housing, nutrition, and other community-based services.
• Maintain a trauma-informed, client-centered approach that demonstrates empathy, cultural humility, and professionalism.

Care Coordination, Quality & Program Support

• Serve as a lead practitioner by modeling best practices in care navigation, documentation, and client engagement.
• Support consistency and quality in care delivery by sharing tools, resources, and practical guidance with peers as requested.
• Collaborate with the ECM Program Manager to identify service gaps, emerging client needs, and improvement opportunities.
• Participate in case discussions and team meetings to support coordinated care and continuous learning.

Data Collection, Documentation & Reporting

• Accurately document client strengths, needs, services, and outcomes in the case management system within required timelines.
• Conduct routine data quality checks and collaborate with program leadership to ensure data accuracy and completeness.
• Ensure full compliance with HIPAA, confidentiality, and data security standards.
• Monitor client progress toward care plan goals and use data to inform care adjustments and referrals.

Position Special Requirements

• Availability to work occasional evenings and one Saturday per month.
• On-site presence at least two days per week to support collaboration and program operations.
• Availability to work overtime during peak service periods.
• Reliable transportation for regular travel throughout San Diego County.
• Occasional travel within California and the U.S. as required.
• Commitment to promoting a culture of excellence, inclusion, learning, diversity, innovation, and support.