Master of Social Work (MSW)

“Every person deserves compassion, dignity, and the safety of a place to call home.” Homelessness is the largest social and public health crisis in California. Illumination Health + Home is a growing non-profit organization dedicated towards disrupting the cycle of homelessness by providing targeted, interdisciplinary services in our recuperative care centers, emergency shelters, housing services and children's and family programs. IF currently has 13+ facilities with 22+ micro-communities scattered across Orange County, Los Angeles County and the Inland Empire. Role The Behavioral Health Worker supports Illumination Health + Home’s Enhanced Care Management (ECM) program in the Riverside region through community-based behavioral health engagement, screening support, referral coordination, and follow-up for members with mental health, substance use, and complex social needs. The position works within the multidisciplinary ECM team and supports the assigned Lead Care Manager (LCM), who retains responsibility for overall member care coordination and the Care Management Plan. This is a non-clinical coordination role unless the employee holds additional credentials and is expressly authorized to perform clinical functions. The role does not independently diagnose, provide psychotherapy, or make clinical treatment decisions. Pay range from $72,000 - $79,040 per year. Schedule is Monday - Friday from 8:30am - 5pm. Responsibilities Behavioral Health Engagement Build trusting, culturally responsive relationships through trauma-informed, person-centered engagement and motivational interviewingConduct in-person member visits at shelters, housing sites, healthcare facilities, and other appropriate community settings in Riverside County; use phone or telehealth when appropriateIdentify barriers to treatment, including transportation, housing instability, access to providers, and difficulty navigating servicesCoordinate with the LCM to re-engage members with unmet behavioral health needs and document outreach and outcomes Behavioral Health Screening and Clinical Escalation Assist with approved behavioral health screening and monitoring, including PHQ-9 and Brief Addiction Monitor (BAM), only when trained and authorizedCommunicate concerning screening findings, deterioration, substance-related risks, and other changes promptly to the LCM and appropriate licensed practitionerFollow IHH crisis and emergency procedures for imminent safety concerns; do not independently diagnose or determine treatmentSupport measurement-based care by tracking assigned follow-up activities and communicating changes in member functioning and needs Care Coordination and Referral Follow-Up Coordinate referrals and warm handoffs to outpatient mental health, psychiatry, specialty mental health, Drug Medi -Cal/SUD services, crisis resources, and community supportsTrack referrals through appointment scheduling, linkage, follow-up, or documented barriers and report gaps to the LCMCollaborate with the LCM on behavioral health goals in the member’s Care Management Plan and support monthly updates and changes in statusAssist with transitions after ED visits, hospitalization, psychiatric care, or detoxification; coordinate with the LCM on required post-discharge follow-up Multidisciplinary Team Collaboration Participate in regular multidisciplinary team conferences, case discussions, practice coaching, and coordinated service planningWork with nurses, medical providers, LCMs, community health workers, and external behavioral health providers while respecting role boundariesProvide community-based, in-person availability within the contracted Riverside service region Documentation and Encounter Compliance Document each ECM service, outreach attempt, referral, and follow-up accurately in the designated care management documentation system (CMDS) or approved alternativeSubmit timely documentation for encounter reporting; every ECM service must be reported using the appropriate applicable HCPCS code and staff classificationCoordinate with the LCM to support at least two qualifying ECM services per enrolled member per calendar month; this is a team-level engagement requirement, not two behavioral-health visits by this workerFollow privacy and consent rules, including HIPAA, California confidentiality laws, and 42 CFR Part 2 where applicableMaintain accurate records supporting audit readiness, service quality, and non-duplication of care management services Expectations Maintain professionalism, confidentiality, respectful communication, and sound judgment in all member and partner interactionsProvide primarily in-person, community-based support and maintain availability within the Riverside regionEscalate urgent safety concerns immediately and other significant clinical concerns promptly to licensed staffComplete assigned service documentation within 24–48 hours under IHH internal expectations; follow any shorter applicable plan deadlinesParticipate in required program webinars, monthly practice coaching, and semiannual learning sessionsComplete care management documentation system introductory training within 30 business days of hire when applicableIf classified as a Community Health Worker on the ECM care team, complete the required nine-week CHW curriculum or an approved equivalentSupport continuous improvement, reliable referral follow-up, and timely communication with ECM leadership We uphold the values of Community, Action, Respect, and Empowerment in all aspects of our work Community We lead with the vision of a strengthened and compassionate community for all. By embodying collective care, we serve as an example of what is possible when we come together. Action Our “whatever it takes” mindset drives us forward. We take initiative, step in where others have stepped out, and create solutions when none exist. Respect We deeply value the dignity and uniqueness of every individual we serve. We honor their stories, their journeys, and their right to be seen and heard. Empowerment We heal—always. Our work enables clients to grow stronger in health, confidence, and belief in their potential as they move forward on their life journey. Preferred Experience/Minimum Qualifications Required: Bachelor’s degree in Social Work, Psychology, Behavioral Health, Human Services, Counseling, or a closely related field; an equivalent combination of relevant education and direct service experience may be considered by IHHAt least two (2) years of experience providing behavioral health support, case management, community-based outreach, care coordination, or related direct services to individuals with complex health and social needsDemonstrated knowledge of mental health and substance use disorders, behavioral health treatment and referral pathways, trauma-informed care, crisis recognition and escalation, confidentiality requirements, and professional scope of-practice boundariesAbility to conduct regular in-person community visits throughout the Riverside service region; reliable transportation and ability to meet applicable driving requirements when driving is an essential job dutyProficiency with electronic health records or care management documentation systems, timely case notes, referral tracking, and accurate service encounter documentationAbility to work collaboratively with Lead Care Managers, nurses, licensed behavioral health providers, and community partners; willingness to complete required onboarding, screening-tool training, and ongoing program competencies Preferred: Master of Social Work (MSW) degree from a CSWE-accredited program strongly preferred; active California Associate Clinical Social Worker (ASW) registration with the Board of Behavioral Sciences highly desirableMSW graduates eligible to pursue ASW registration are encouraged to apply. Any clinical duties assigned to an ASW require appropriate supervision, authorization, and compliance with California scope-of-practice rulesExperience with Medi-Cal, CalAIM ECM, homelessness services, serious mental health needs, substance use disorders, and behavioral health treatment coordinationExperience with PHQ-9, BAM, motivational interviewing, trauma-informed care, crisis identification, and multidisciplinary teams; CHW or peer support certification is a plus where relevant to the applicable staffing classificationBilingual English/Spanish Benefits Medical Insurance funded by Illumination Health + Home (Kaiser and Blue Shield), depending on the planDental and Vision InsuranceLife, AD&D and LTD Insurance funded 100% by Health + HomeEmployee Assistance ProgramProfessional Development Reimbursement401K with Company Matching10 days vacation PTO/year6 days sick PTO/year10 days holiday PTO/yearPotential eligibility for the Public Service Loan Forgiveness Program (PSFL) for federally qualified loans Powered by JazzHR qKEBehqQ74