Case Manager - Housing & Community Linkage (CalAIM - ECM)

Case Manager – Housing & Community Linkage (CalAIM – ECM) Napa County, CAOrganization: Conscious PuzzlesAbout Conscious PuzzlesConscious Puzzles is a community-based organization committed to trauma-informed care, housing stabilization, and holistic healing for underserved individuals and families in Napa County. Through innovative partnerships and person-centered services, we support individuals experiencing complex health and social needs.We are proud to participate in California’s CalAIM initiative, providing Enhanced Care Management (ECM) services to individuals with high-acuity medical, behavioral health, and social needs.Position OverviewThe Case Manager – Housing & Community Linkage (CalAIM – ECM) provides field-based, intensive case management services under the Enhanced Care Management (ECM) benefit. This role supports Medi-Cal members experiencing homelessness, justice involvement, serious mental illness, substance use challenges, and/or complex medical conditions.This position requires strong systems navigation skills, collaboration with managed care plans, and high-touch engagement to reduce hospitalizations, improve stability, and increase housing security.Key Responsibilities Housing Navigation & Stabilization (ECM Focus)Conduct comprehensive assessments addressing housing, health, behavioral health, and social determinants of healthAssist members with emergency shelter, transitional housing, permanent supportive housing, and landlord coordinationSupport documentation for housing eligibility and benefitsCollaborate with managed care plans and community-based housing providers Enhanced Care Management (ECM) CoordinationDevelop individualized care plans aligned with CalAIM ECM standardsCoordinate care across medical providers, behavioral health clinicians, substance use treatment programs, and social servicesParticipate in interdisciplinary care team meetingsConduct field-based visits (home, hospital, community settings)Provide warm handoffs and active follow-up to ensure successful linkage Documentation & ComplianceMaintain timely documentation consistent with CalAIM ECM requirementsTrack referrals, service delivery, and measurable outcomesEnsure compliance with Medi-Cal managed care plan standardsMonitor client progress and update care plans regularly Advocacy & Client EmpowermentUtilize trauma-informed, culturally responsive practicesAdvocate within healthcare and social service systemsSupport clients in achieving self-sufficiency and long-term stabilityTarget Population (CalAIM – ECM)This role serves individuals who may be:Experiencing homelessness or at risk of homelessnessHigh utilizers of emergency departments or inpatient servicesLiving with serious mental illness or substance use disordersJustice-involvedManaging complex chronic medical conditionsQualificationsRequired:Bachelor’s degree in Social Work, Psychology, Human Services, or related field (or equivalent experience)Minimum 1–2 years of case management experienceExperience working with high-acuity or vulnerable populationsKnowledge of Medi-Cal, managed care systems, or public benefitsStrong documentation and care coordination skillsPreferred:Experience working within CalAIM or ECM programsBilingual (Spanish preferred)Experience with EHR or HMIS systemsKnowledge of harm reduction and trauma-informed care modelsCore CompetenciesUnderstanding of social determinants of healthHigh-level engagement and outreach skillsCrisis de-escalation and problem-solvingStrong collaboration with healthcare systemsAbility to manage complex caseloadsEthical and professional practiceWhat Success Looks Like in 12 MonthsIncreased number of ECM members successfully stabilized in housingReduced emergency department utilization among assigned caseloadStrong collaborative relationships with managed care plansImproved health and social outcomes for enrolled membersCompensation & ScheduleFull-time or part-time positions availableField-based and hybrid opportunitiesCompetitive salary based on experienceOngoing professional development and CalAIM trainingHow to ApplyPlease submit:ResumeCover letter describing your experience with high-acuity populations and care coordinationSend your Resume to: Consciouspuzzles@gmail.com or Call 4242-320-1192

Salary : $23 - $25