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 appointme…