Lead Care Manager

Lead Care Manager, Enhanced Care Management

**This position is for Kern County Brain Injury Foundation. BlueRidge Management Solutions, LLC is assisting with the recruitment of this position.**

ORGANIZATIONAL OVERVIEW:

Kern County Brain Injury Foundation is a CalAIM provider, offering comprehensive supportive services that address the full spectrum of human needs, including physical health, social wellbeing, behavioral health, and beyond. KCBIF is dedicated to improving the overall health and well-being of the community by providing solutions that recognize the interconnected nature of health and wellness. Targeting individuals with complex physical, behavioral, and social needs, KCBIF provides ECM and Community Supports services to those in need.

DESCRIPTIONS & PURPOSE:

This full-time position provides intensive, person-centered care coordination to high-need Medi-Cal members—often those experiencing homelessness, complex medical conditions, or behavioral health challenges. The role blends direct service delivery with program oversight and interagency collaboration.

The role involves working in a hybrid environment with frequent field visits to service sites, community partners, and member locations. This position is critical for achieving positive health outcomes for high-need, high-cost Medi-Cal beneficiaries.

COMPETENCIES:

• Strong interpersonal skills, cultural humility, and ability to work with vulnerable populations
• Proficiency in Microsoft Office and electronic health record systems
• Build trust with members who may lack support networks; use empathy, active listening, and motivational interviewing
• Evaluate medical, behavioral, housing, and social needs; develop individualized care plans aligned with ECM goals
• Navigate complex systems across Medi-Cal, behavioral health, housing, and social services; ensure continuity of care
• Provide health education materials, promote preventive care, and support chronic condition management
• Assist members during transitions (e.g., hospital discharge, shelter exit); reduce readmissions and service gaps
• Link members to benefits, housing, food, employment, and legal aid; advocate for member needs across systems
• Maintain accurate records in HMIS or EHR systems; complete assessments, referrals, and billing documentation on time
• Work with MCPs, primary care, behavioral health, and community-based organizations; attend multidisciplinary meetings
• Deliver services with cultural humility and sensitivity to diverse backgrounds and lived experiences

RESPONSIBILITIES:

• Care Coordination: Deliver ECM core services including outreach, assessment, care planning, health promotion, transitional care, and referrals to social supports
• Client Engagement: Build rapport with members who may lack support networks; conduct regular check-ins and accompany clients to appointments
• Assessment & Planning: Evaluate needs across physical health, behavioral health, housing, food security, employment, and benefits; develop and monitor individualized care plans
• Service Navigation: Link members to housing programs, public benefits, medical providers, behavioral health services, and community-based organizations
• Documentation & Compliance: Maintain accurate records in Health Management Information Systems (HMIS); ensure timely completion of assessments, authorizations, and billing documentation
• Collaboration: Work closely with Managed Care Plans (MCPs), primary care providers, behavioral health teams, and housing navigators to coordinate services
• Program Support: Participate in multidisciplinary team meetings, quality improvement initiatives, and internal process optimization
• Other duties as assigned

QUALIFICATIONS:

• High School Diploma or GED: Associate’s or Bachelor’s degree in Social Work, Public Health, Psychology, Nursing, or a related field is strongly preferred
• Experience in case management, social work, or health navigation (2 years preferred)
• Experience with Medi-Cal programs, managed care operations, and knowledge of CalAIM initiatives strongly preferred
• Demonstrated experience with electronic health records, case management systems, and data reporting platforms
• Current valid driver's license and reliable transportation for field visits

WORKING CONDITIONS:

• Full-time
• Hourly Pay Range: $18.25 - $22.50
• Benefits: sick pay, vacation time, and holiday pay
• During standard business hours Monday through Friday with occasional evening or weekend availability for urgent matters
• Regular travel required within service counties for provider meetings, site visits, and community engagement activities (approximately 25-30% travel)
• Must be able to respond to after-hours urgent requests for services when necessary

Pay: $18.25 - $22.50 per hour

Benefits:

• Paid time off
• Paid training

Work Location: In person

Salary : $18 - $23