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. The LCM develops individualized care plans, coordinates medical, behavioral health, substance use disorder, and social services, and collaborates closely with members, families, healthcare providers, correctional systems, and community organizations to ensure continuity of care and successful community reintegration. The LCM supports members with complex medical, behavioral health, housing, and social determinants of health needs through field-based outreach, advocacy, care coordination, and ongoing member engagement. Candidates with experience working with justice-involved populations, behavioral health, homelessness services, reentry programs, or substance use treatment are strongly preferred. Lived experience is valued when combined with the ability to maintain professionalism, boundaries, and essential job responsibilities.

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.
• Coordinate physical health, behavioral health, substance use treatment, housing, transportation, and community support services.
• Collaborate with interdisciplinary care teams, healthcare providers, correctional facilities, probation/parole departments, and community-based organizations.
• Assist members with successful community reintegration, linkage to healthcare services, benefits enrollment, medication continuity, and housing stabilization.
• Support members in reducing avoidable emergency department utilization and barriers to long-term health stability.
• Maintain ongoing contact with members through in-person visits, telehealth, phone outreach, and community engagement.
• Advocate for members and assist with scheduling appointments, accessing treatment, and overcoming healthcare and social barriers.
• Maintain accurate, timely, and compliant documentation in accordance with DHCS, Medi-Cal, HIPAA, and organizational standards.
• Provide trauma-informed, culturally responsive, and member-centered care to diverse populations.
• Maintain professionalism, empathy, and ethical conduct while interacting with members, families, providers, and community partners.
• Participate in trainings, case conferences, supervision, audits, and quality improvement initiatives.
• Perform additional duties as assigned.

Populations of Focus:

• Individuals transitioning from incarceration or correctional settings within the past 12 months will be the priority population of focus.
• Individuals experiencing homelessness or housing instability.
• Individuals with serious mental illness and/or substance use disorders.
• Individuals at risk for avoidable hospital or emergency department utilization.
• Adults living in the community and at risk for long-term care institutionalization.
• Children and youth involved in child welfare or juvenile justice systems.
• Individuals with intellectual and/or developmental disabilities who qualify under ECM populations of focus.
• Pregnant and postpartum individuals experiencing health disparities or qualifying under ECM populations of focus.

Education and Experience:

• High school diploma or GED required.
• Associate degree or higher in social work, psychology, healthcare, criminal justice, human services, or related field preferred.
• Minimum of one (1) year of experience in case management, care coordination, behavioral health, healthcare outreach, reentry services, or related field required.
• Experience working with justice-involved populations strongly preferred.
• Experience with Medi-Cal, CalAIM, ECM, behavioral health, homelessness services, or substance use treatment preferred.
• Valid California driver's license, reliable transportation, and current automobile insurance required.

Required Skills/Abilities:

• Excellent communication, interpersonal, customer service, and organizational skills.
• Ability to engage vulnerable and hard-to-reach populations using trauma-informed and culturally responsive approaches.
• Comfortable conducting in-person visits with members in correctional settings to support engagement and care coordination.
• Strong documentation, computer, email, and electronic health record skills.
• Ability to work independently and collaboratively within multidisciplinary teams.
• Strong problem-solving, critical thinking, and resource coordination skills.
• Ability to manage multiple members and priorities in a fast-paced environment.
• Knowledge of community resources, behavioral health systems, and social service programs preferred.

Physical Requirements:

• Must be able to travel using personal vehicle to complete outreach visits and community-based member support.
• Mileage reimbursement provided at the IRS standard rate.
• Prolonged periods of sitting, standing, driving, and computer use.
• Ability to occasionally lift up to 15 pounds.