Recuperative Care- Case Manager

Our Mission At Whole Person Care Clinic (WPCC), our mission is to provide holistic, compassionate, and accessible care that nurtures the physical, emotional, and social well-being of every individual we serve. Through an integrated approach that combines medical expertise, mental health support, and community services, we are dedicated to addressing the full spectrum of our patients' needs. By fostering a collaborative and inclusive environment, we empower individuals to achieve their highest quality of life and well-being, regardless of their socioeconomic status. We strive to create a supportive community where every person is valued, heard, and cared for with dignity and respect.

Position Summary

The Case Manager provides direct, trauma-informed case management services to individuals experiencing homelessness and to patients enrolled in Recuperative Care (also known as Medical Respite) programs. This role serves as a critical bridge between acute medical care, behavioral health care, housing stability, and community-based support services, guiding clients through complex systems with compassion and advocacy. In addition to demonstrating professionalism and reliability, the ideal candidate brings a working knowledge of local community resources, a foundational understanding of medical and behavioral health terminology, and care settings, and a basic familiarity with Medi-Cal insurance and eligibility processes. Core Responsibilities Case Management & Client Services Conduct comprehensive intake assessments to identify clients' housing, medical, behavioral health, social, and basic needs. Develop individualized service plans with measurable goals in collaboration with clients, clinical staff, and partner agencies. Provide regular case management check-ins, adjusting service plans as client needs evolve. Facilitate coordination of care for clients with existing service providers, including prompt and reliable communication with outside agencies and service providers. Maintain accurate, timely case notes and documentation in the agency's case management information system (HMIS or equivalent). Coordinate safe discharge planning for Recuperative Care patients transitioning back to community settings, including ensuring continuity of care upon discharge. Support clients to self-advocate with landlords, government agencies, healthcare providers, and social service systems, intervening to assist and advocate on behalf of client as appropriate. Community Resource Navigation Have a working knowledge of and maintain an up-to-date database of local resources, including but not limited to housing programs, basic needs services, behavioral health providers, domestic violence support, legal services, employment/vocational programs, transportation services, etc. Build and maintain referral relationships with community partners to facilitate continuity of care. Connect clients to benefits they are entitled to, including SSI/SSDI, CalFresh, and CalWORKs. Medical Support & Recuperative Care Coordination Understand and communicate basic medical information relevant to client care, including common diagnoses seen in the unhoused population (e.g., wound care needs, diabetes management, post-surgical recovery). Understand and communicate basic behavioral health information relevant to client care, including common diagnoses seen in the unhoused population (e.g., substance use withdrawal management, commonly misused substances, brief behavioral health intervention techniques, common mental health disorders, coping skills development). Accurately document observations and behaviors using appropriate medical and behavioral health terminology, communicating to nursing, clinical, and support staff in a timely manner. Monitor client adherence to prescribed treatment plans, medication schedules, and engagement in care, reporting concerns to clinical supervisors. Coordinate follow-up medical and behavioral health appointments and assist clients with transportation to health care visits. Recognize signs of medical distress or behavioral health crises and respond according to established protocols. Medi-Cal & Insurance Navigation Assist clients in applying for and maintaining Medi-Cal coverage, including Covered California where applicable. Demonstrate a basic understanding of Medi-Cal eligibility categories, managed care plans, and covered services. Help clients understand their insurance benefits and connect them with covered services such as pharmacy, mental health care, substance use disorder treatment, and specialist care. Coordinate with Medi-Cal managed care plan care coordinators and other service providers when appropriate to avoid duplication of services. Refer clients to a benefits specialist or social worker for complex insurance issues beyond the scope of this role.

Qualifications

Required Bachelor's degree in social work, Psychology, Public Health, Human Services, or a related field - OR - equivalent combination of education and relevant work experience. Minimum 1-2 years of case management or social services experience, preferably in homeless services, recuperative/medical respite care, or a similar setting. Demonstrated knowledge of local community resources and social service systems. Ability to work effectively with individuals experiencing homelessness, mental illness, substance use disorders, and complex medical conditions. Proficiency in basic computer applications and electronic case management systems. Valid driver's license and reliable transportation (if required for client transport duties). Preferred Experience in a medical respite, skilled nursing, hospital, or clinic settings. Familiarity with Medi-Cal/Medicaid systems, managed care plans, and/or benefits enrollment. Bilingual or multilingual skills (Spanish strongly preferred). Certification in Mental Health First Aid, CPR/First Aid, or Motivational Interviewing. HMIS or comparable database experience. Core Competencies Trauma-Informed Practice - Demonstrates sensitivity to trauma histories; maintains professional boundaries while building trust. Cultural Humility - Provides equitable, inclusive services across diverse populations. Communication - Communicates clearly in writing and verbally with clients, clinical staff, and partner agencies. Problem-Solving - Approaches complex barriers with creativity and persistence. Organization & Time Management - Manages a caseload of multiple clients with competing needs and deadlines. Collaboration - Works cooperatively within an interdisciplinary team and with external partners. Working Conditions & Physical Requirements Indoor/outdoor site environment with movement between client areas and administrative offices Ability to lift up to 25 lbs, assist clients with mobility support as needed PPE required; adherence to infection control protocols Prolonged periods of standing, walking, and computer use Schedule and Travel Requirements Full-time (40+ hours/week), Non-exempt Some evening, weekend, or on-call hours may be required EEO / ADA Statement WPCC is an Equal Opportunity Employer. We are committed to fostering a diverse and inclusive work environment and comply with all applicable federal, state, and local employment laws. WPCC provides reasonable accommodation to qualified individuals with disabilities. Disclaimer This job description is not designed to cover or contain a comprehensive list of activities, duties, or responsibilities required for the position. Duties and responsibilities may change at any time with or without notice.