Base pay range $27.00/hr - $29.50/hr
Position summary The CalAIM Case Manager provides person-centered care coordination and support for individuals with complex medical, behavioral, and social needs enrolled in California’s Enhanced Care Management (ECM) and Community Supports (CS) programs. Serving as the primary point of contact and advocate, this role ensures clients receive the services and resources they need to improve health, stability, and overall well-being. Working closely with healthcare providers, behavioral health professionals, housing and social service agencies, and community organizations, the CalAIM Case Manager develops individualized care plans, addresses barriers to care, and empowers clients through health education and coaching. This role will also coordinate with Housing Navigators to deliver Housing Navigation or Housing Tenancy services for clients dually enrolled in Community Supports, with the goal of promoting long-term independence and self-sufficiency.
Role & Responsibilities Outreach & Engagement
Actively locate, contact, and engage clients who have been identified as eligible for ECM and Community Supports.
Use culturally and linguistically appropriate outreach strategies to build trust and establish rapport.
Conduct in-person meetings with clients in the community or at provider locations to assess their needs and preferences. Document all outreach and engagement efforts thoroughly and in a timely manner.
Assessment & Care Management
Conduct comprehensive assessments to identify physical, behavioral, social, and environmental needs.
Collaborate with clients and supervisors to develop individualized, person-centered care plans that reflect client goals and preferences.
Address social determinants of health (housing, food insecurity, transportation) within care plans.
Provide ongoing support by accompanying clients to important appointments, offering transportation when needed, and helping navigate complex health systems.
Reassess needs regularly and update care plans as circumstances change.
Enhanced Coordination of Care
Serve as the primary point of contact for clients, coordinating communication and collaboration among all providers involved in their care.
Act as a liaison among healthcare, behavioral health, housing, and community-based providers to ensure coordinated service delivery.
Facilitate referrals to primary care, specialists, behavioral health services, and community resources.
Schedule and remind clients of appointments, arrange transportation, and reduce barriers such as health literacy or psychosocial challenges.
Advocate for client needs while promoting client voice and participation in decision-making.
Establish strong relationships with clients and families, providing practical and emotional support.
Health Promotion & Education
Deliver psychoeducation on proactive healthcare engagement.
Educate clients on attending and preparing for regular medical appointments and risks of unmanaged conditions.
Provide health education on chronic disease management, healthy behaviors, and preventive services (nutrition counseling, smoking cessation).
Support clients in building daily living skills and long-term self-sufficiency.
Coordination & Referrals
Connect clients to housing, food pantries, transportation, and public benefits.
Facilitate access to Community Supports (housing transition navigation, medically tailored meals, respite care).
Follow up to confirm services are received and troubleshoot barriers.
Documentation & Compliance
Maintain accurate records of client contacts, intake forms, assessments, eligibility documentation, and referrals in the EHR.
Ensure compliance with program requirements, HIPAA, and confidentiality protocols.
Contribute to data quality assurance, reporting, and continuous quality improvement.
Collaboration & Program Participation
Participate in multidisciplinary meetings, trainings, and case reviews.
Collaborate with internal teams and external partners; contribute to program development and quality improvement.
Job requirements Mature and personal Christian faith
Commitment to World Relief’s mission, vision, and values
Desire to empower vulnerable communities and affirm World Relief’s Core Beliefs and related documents
Bachelor’s degree in Social Work, Psychology, Nursing, or related field; OR Associate’s with relevant experience; OR equivalent
Minimum of 2 years of experience in case management or related social services
Strong cultural competency and sensitivity to diverse populations
Experience with immigrant or vulnerable populations (homelessness, serious mental illness, substance use, justice involvement, complex health conditions)
Proficient verbal and written English communication; bilingual/multilingual in a common client language (e.g., Dari, Pashto) is a plus
Knowledge of HIPAA and commitment to client privacy and data security
Valid driver’s license, current auto insurance, and reliable transportation
Preferred qualifications Familiarity with Medi-Cal, CalAIM, and managed care systems
Medical terminology and chronic health conditions knowledge
Knowledge of local housing resources and community-based services
Trauma-informed, client-centered, strengths-based service delivery
Excellent interpersonal, organizational, and written communication skills
Proficient in documentation and case notes in electronic health systems
Ability to manage complex issues, multiple priorities, and work independently or collaboratively
Ability to maintain positive professional relationships with clients, colleagues, agencies, and partners
World Relief offers a competitive benefits package and employee discount program for full-time and part-time employees.
World Relief is honored to be recognized with the Gold-level Cigna Healthy Workforce Designation for well-being program excellence.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing.
For World Relief staff, strong commitment to the mission, vision, and values is essential, and Christian faith is a prerequisite for employment, per Title VII guidelines.