Lead Care Manager at FundaMental Health

Job Title: Lead Care Manager

Program: Bridge to Care

Department: Operations

Reports to: Program Director

FT/PT: Full-Time

FLSA Status: Non-Exempt

Pay Range: $26.00 - $28.00 per hour

Works in collaboration with:   Program Director, Care Navigators, Managed Care Plans, community partners

Position Description

FundaMental Health is seeking a compassionate, detail-oriented Lead Care Manager (LCM) to deliver Enhanced Care Management (ECM) services to high-need Medi-Cal members in San Diego County. The LCM serves as the primary point of care coordination for assigned members, providing outreach, assessment, person-centered care planning, and ongoing coordination across medical, behavioral health, and social service systems. This role requires strong engagement skills, excellent documentation, and comfort working independently in community settings while collaborating closely with a multidisciplinary team.

This is a fully remote, field-based role supporting individuals with complex medical, behavioral health, and social needs, including individuals experiencing homelessness, serious mental illness, substance use disorders, and other CalAIM populations of focus. LCMs work independently from a home office and in the community and do not report to a physical office location. All meetings, supervision, training, and documentation are completed remotely, while direct service delivery occurs in community settings throughout San Diego County.

Essential Job Duties and Responsibilities:

• Deliver ECM services in compliance with CalAIM, DHCS, Managed Care Plan, and FundaMental Health ECM Program Manual requirements.
• Conduct outreach and engagement using in-person visits, phone, text, and community-based contact, prioritizing in-person engagement whenever feasible.
• Complete comprehensive ECM assessments addressing medical, behavioral health, substance use, and social determinants of health.
• Develop, implement, and continuously update individualized, person-centered care plans in collaboration with members and care teams.
• Serve as the primary point of contact for assigned members, their authorized supports, and the multidisciplinary care team, ensuring seamless coordination and preventing duplication of services.
•  Coordinate care across primary care, behavioral health providers, hospitals, specialty care, housing providers, and community-based organizations.
• Support transitions of care, including hospital discharge, incarceration re-entry, institutional transitions, and housing changes.
• Advocate for members to reduce barriers to care and improve access to needed services.
• Maintain frequent, meaningful contact with members consistent with ECM acuity and engagement requirements.
• Complete accurate, timely, and audit-ready documentation, including assessments, care plans, outreach logs, progress notes, and encounter records, in accordance with DHCS and MCP standards.
• Participate in virtual team meetings, case conferences, trainings, and clinical supervision.
• Follow all Safety in the Field, crisis response, escalation, and incident reporting protocols.
• Perform mandated reporting duties in accordance with California law and agency policy.
• Adhere to HIPAA, confidentiality, fraud, waste, and abuse (FWA) prevention standards.
• Perform other related duties as assigned.

Competencies and Qualifications:

Required:

• High school diploma or GED.
• Minimum 1 year experience providing enhanced care management, case management, care coordination or related services. 
• Experience working with underserved or high-acuity populations, including individuals with mental health needs, substance use disorders, homelessness, or justice involvement.
• Demonstrated ability to work safely in community and field-based settings, including use of de-escalation strategies and crisis response protocols.
• Strong interpersonal, engagement, and communication skills.
• Ability to work independently in the field while collaborating effectively with a remote team.
• Excellent organizational skills with attention to detail and follow-through.
• Proficiency with electronic documentation systems and Google Workspace tools.
• Reliable transportation, valid California driver’s license, and active auto insurance.
• Ability to pass required background checks and health screenings per county and payer requirements.

Preferred:

• Bachelor’s degree in Social Work, Public Health, Psychology, Human Services, or a related field.
• Prior experience in ECM, Whole Person Care, Health Homes, or CalAIM-funded programs.
• Bilingual in Spanish or another threshold language.
• Familiarity with San Diego County health, behavioral health, housing, and social service systems.
• Training in trauma-informed care, motivational interviewing, or harm reduction.

General Expectations:

• Demonstrates commitment to FundaMental Health’s mission, values, and equity-centered approach to care.
• Upholds high standards of professionalism, ethics, and accountability.
• Maintains timely, accurate documentation and responsiveness to team communications.
• Models respect, cultural humility, and client dignity in all interactions.
• Understands and complies with Fraud, Waste, and Abuse (FWA) prevention requirements, including accurate representation of member engagement and services provided.
• Actively contributes to a collaborative, growth-oriented team culture.

Work Environment:

This is a remote-first, field-based role with no in-office reporting location. The LCM maintains a secure home workspace for administrative duties and participates in supervision and meetings virtually. Fieldwork is conducted independently in community settings across San Diego County, including homes, shelters, clinics, and partner organizations. Reliable internet access and the ability to work autonomously are essential.

Physical Requirements:

☒ Seeing                                            ☒ Hearing                                          ☒ Speaking

☒ Stooping/Bending                           ☒ Working in cramped spaces            ☒ Moving around facility

☒ Moving between offices/clients        ☒ Driving                                           ☒ Climbing

☒ Lifting/carrying heavy items            ☒ Pushing/pulling/dragging items        ☒ Standing for long periods

☒ Working outside/underground         ☒ Using hands/fingers                       ☒ Sitting for long periods