Lead Case Manager - HOPE CalAIM FCC

Job Description

Job Description

Position Summary

The Lead Case Manager is responsible for providing direct services to clients referred to the Hope CalAIM FCC Program. This position plays a critical role in coordinating care among multiple providers and addressing clients’ medical, behavioral, and social service needs. The Lead Case Manager creates individualized care plans that meet health plan requirements and address barriers to care, including providing health education and coaching to promote long-term self-sufficiency.

The Lead Case Manager also serves as the primary point of contact for a client’s care team, which may include primary care providers, behavioral health professionals, housing support services, SUD providers, and natural supports. If a client is dually enrolled in CalAIM Community Supports, the Lead Case Manager may also provide Housing Navigation or Housing Tenancy services as needed.

Essential Duties and Responsibilities

The essential functions include, but are not limited to the following :

Serve as the Lead Case Manager for assigned clients

Maintain accurate and timely documentation and client records in compliance with program requirements

Provide "hand-holding" services, including accompanying clients to initial appointments and helping them navigate health systems

Deliver psychoeducation and teach clients the importance of addressing medical needs proactively

Educate clients on how to attend and prepare for regular medical appointments

Provide guidance on how untreated or unmanaged medical conditions may worsen over time

Act as a liaison among all of the client’s providers, ensuring coordinated and integrated service delivery

Advocate for the client’s needs while promoting client voice and choice in all aspects of care

Support clients in accessing essential needs, such as food, transportation, housing, and public benefits

Help clients develop daily living skills and long-term self-sufficiency

Identify and reduce barriers to care, including transportation, health literacy, or psychosocial challenges

Participate in multidisciplinary team meetings and collaborate with community partners

Minimum Qualifications (Knowledge, Skills, and Abilities)

Minimum of 2 years of experience in case management, care coordination, or a related social services role

Knowledge of the Fresno Madera Continuum of Care and Housing Services

Strong knowledge of medical terminology and chronic health conditions

LVN (Licensed Vocational Nurse) certification highly recommended

Prior experience working with individuals experiencing homelessness, serious mental illness, substance use disorder, or complex physical health conditions preferred

Familiarity with Medi-Cal, CalAIM, or managed care systems is a plus

Demonstrated ability to provide compassionate, client-centered care and health education

Excellent interpersonal, organizational, and written communication skills

Proficient in documentation and case noting in electronic systems