Responsibilities
- Carry a panel of ECM-enrolled patients with behavioral health needs, including serious mental illness (SMI), substance use disorders (SUD), and co-occurring conditions, as part of a collaborative pod model.
- Conduct behavioral health screenings and assessments to inform individualized care plans, developed in partnership with the patient and the interdisciplinary team.
- Provide direct patient support using motivational interviewing, harm reduction, and trauma-informed approaches—meeting members in the community, at clinics, or by phone.
- Serve as the team’s go-to resource for behavioral health questions, warm handoffs, and crisis response protocols—ensuring that patients presenting with suicidality, acute mental health concerns, or SUD crises are appropriately triaged and connected to care.
- Connect patients to mental health services, peer support programs, crisis lines, and other community resources in the Inland Empire.
- Collaborate daily with the RN Care Manager, Care Coordinator, CHW, and Program Manager to coordinate whole-person care for patients with complex needs.
- Participate in daily huddles, weekly case conferences, and care planning meetings as the behavioral health voice on the team.
- Support smooth transitions and warm handoffs to county behavioral health, inpatient, and crisis services as needed.
- Communicate with PCPs, specialists, and community-based partners regarding patient’s behavioral health status and care coordination needs.
- Document all encounters accurately and timely in Care Director in compliance with IEHP ECM program requirements, CalAIM standards, and HIPAA.
- Contribute to audit preparation, quality improvement initiatives, and metric gap closure in collaboration with the ECM Program Manager and Director.
Requirements
- MSW or MFT
- California licensure (LCSW/LMFT) preferred
- Reside locally to the region served
- Minimum 2 years of experience in behavioral health case management, care coordination, or direct services with Medi-Cal or similarly complex populations
Nice to Have
- Experience with Medi-Cal/Medicaid populations, CalAIM, or ECM programs
- Familiarity with IEHP and the Inland Empire county behavioral health system
- Experience working with populations experiencing homelessness, justice involvement, or high emergency department utilization
- Bilingual English/Spanish
Work Arrangement
Remote (City/Region)
Team
Structure: Interdisciplinary ECM team alongside a Registered Nurse, Care Coordinator, and Community Health Worker
Additional Information
- Valid California Driver’s License, reliable transportation, and ability to travel locally across the Inland Empire for in-person visits.
