The Intensive Case Manager (ICMS) supports and promotes LACHC’s mission to follow Christ by loving and serving our neighbors through comprehensive, quality healthcare. The mission will be upheld in the job duties of the Intensive Case Manager. The Intensive Case Manager (ICMS) will work with assigned DHS Housing for Health patients by assisting them in achieving and maintaining good health, including providing them with access to medical, mental health and other adjunctive services, and working towards housing stability.
ESSENTIAL DUTIES and RESPONSIBILITIES include:
- Use effective communication skills such as active listening and reflective listening to build rapport with vulnerable and difficult to engage clients who are homeless.
- Assess clients’ stage of change and readiness for self-management and utilize appropriate motivational interviewing interventions to address each stage.
- Apply behavioral interventions such as motivational interviewing that increase positive outcomes and optimize patient well-being.
- Interview and evaluate clients to identify social, emotional, and economic factors which may interfere with attaining stability and optimum health.
- Develop social assessments and formulate treatment plans based on evaluation of the patient’s past, present, and future medical and socioeconomic functioning.
- Perform outreach and engagement services to patients in the community
- Process and accept referrals from DHS and other Housing for Health partners as directed by DHS
- Obtain all appropriate consents for services and authorizations for clients participating in Intensive Case Management Services (ICMS)
- Document client contacts in the DHS electronic health care record called CHAMP ( and possibly ECW if warranted); keeping Supervisor abreast of patients that need to be closed due to lack of participation in Housing for Health OR the choice to voluntarily terminate from the HFH program
- Develop a case management treatment plan based on the client’s stated needs ( and updating this plan quarterly)
- Linking clients to appropriate resources, including these: substance abuse treatment programs, legal services, mental health care, HIV and AIDS services, recuperative care, immigration services shelter services, clothing and food resources.
- Assisting clients with linkage to benefits establishment, such as General Relief (GR) and food stamps, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI), Medi-Cal, and Veterans Administration benefits for eligible homeless individuals.
- Provide assistance with requesting copies of out-of-state birth certificates and other identification as needed
- Assist patients with accessing temporary housing through mechanisms such as DHS funded interim housing, LAHSA bridge housing, and local shelters
- Facilitating housing navigation by searching Section 8 and other related websites, meeting apartment managers in the community, and looking for open rentals by perusing newspapers, magazines, or finding rentals by driving and seeing apartments for rent
- Facilitating with the patient the process before and after they move in to their dwelling place; i.e. securing funding for apartment applications, furniture, kitchen and cleaning supplies, household goods, turning on utility bills (water, gas, trash, electric), heaters, eating utensils, beds, washer/dryer, refrigerator,
- Visiting patients between one and three times a week prior to obtaining housing; visiting patients once per month after patient has lived successfully in their housing for at least one year
- Helping the patient to understand the rules of living in an apartment or other dwelling place in which rules must be followed; helping patient to understand how to prevent being evicted
- Assisting patients with transportation services via Metro Access, obtaining Regular of Disabled Bus Pass, TAP cards, teaching patient how to use public transportation
- Assisting patients with budgeting and housing household management, including cleaning, cooking, household upkeep and cleanliness, non-hoarding behavior
- Linking clients to a representative payee for money management as needed
- Assisting patient with learning and practicing personal grooming and hygiene skills; training the patient on how to develop interpersonal relationship skills; helping patient to create safe and healthy activities for leisure/recreation
- Assisting patient with knowing how to adapt to their new neighborhood (i.e. safety issues, emergency services, knowing where the library, churches, laundromat, pharmacy, schools, hospitals, clinics, grocery stores, cleaners, malls) are located
- Attend community meetings such as sponsored by DHS, LAHSA, The Housing Authority, Department of Mental Health, etc.
- Document all evaluations, care plans, interventions and referrals performed.
- Facilitating any plan for family reunification with clients and their birth families which would result in client leaving their unit
- Participate in individual and group supervision, and case conferences as requested for the discussion of specific patients as well as sharing of training materials and best practices.
- Embracing the DHS philosophy of “whatever it takes” which encompasses how diligent and persistent the ICMS worker is in locating and encouraging a patient to receive supportive including the necessary services needed for optimum health
- Other duties as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- CPR Certification required.
- Bi-lingual Spanish preferred.
EDUCATION and/or EXPERIENCE
Bachelor’s degree in social work or related field from a four-year college or university. Two years of social work experience is preferred. Prior case management experience preferred. Prior experience working with the homeless, substance using, or chronically mentally ill individuals preferred.
Experience with Microsoft Word, Microsoft Access, and Microsoft Excel preferred.
Familiarity with medical terms and operations of clinics useful.
Proficiency in English required, Bi-lingual Spanish recommended.
Regular, Full-time, Non-Exempt position. Medical, Dental, Vision and 403B Retirement
Plan with employer match. We are an equal opportunity employer. We will consider applicants with criminal histories.