Lead Care Manager; LCM

Ground Game.

Health ~ Connecting the Unconnected to Close Health Equity Gaps

lth, our mission is to improve lives by bridging the gap between clinical care and community support. We foster a collaborative, mission-driven culture where every team member plays a vital role in helping members overcome barriers, achieve better health outcomes, and thrive. We are committed to innovation, accountability, integrity, and excellence while empowering our employees to make a meaningful difference in the communities we serve.

We are a technology-enabled care management organization dedicated to improving health outcomes by addressing the social and health-related needs that impact people's well-being. We partner with health plans, provider organizations, and community-based organizations to deliver person-centered care coordination, Enhanced Care Management (ECM), Community Health Integration (CHI), Community Health Worker (CHW), and other value-based care services that improve access to care and reduce health disparities.

Our multidisciplinary teams work alongside providers to identify and address Health-Related Social Needs (HRSNs) and Social Determinants of Health (SDOH), connecting members with healthcare, community resources, and social services that support healthier lives. By combining compassionate, trauma-informed care with innovative technology and data-driven insights, we help ensure every member receives coordinated, equitable, and high-quality care.

We are seeking a compassionate, driven Lead Care Manager to identify, engage, enroll, and support members participating in CalAIM Enhanced Care Management (ECM), Community Health Integration (CHI), Community Health Worker (CHW) services, or other care coordination programs. This role is embedded within one or more provider practices, serving as an extension of both the provider office and Ground Game.

Health. As the primary liaison between physicians, clinical staff, patients, and the Ground Game.

Health care management team, you will integrate social care into the clinical setting by identifying patients with health-related social needs and ensuring they receive timely assessments, care coordination, case management, and connections to healthcare, community, and government resources.

Using trauma-informed, culturally responsive, and person-centered practices, you will build trusting relationships with members and their support systems, educate members on available services, obtain required consents, and provide ongoing support throughout program participation. You will conduct comprehensive Health-Related Social Needs (HRSN) and Social Determinants of Health (SDOH) assessments, identify barriers related to housing, food insecurity, transportation, financial hardship, behavioral health, healthcare access, and other social needs, develop individualized care plans in collaboration with members and interdisciplinary care teams, coordinate referrals, support healthcare navigation and appointment scheduling, monitor referral outcomes, and reassess members throughout enrollment to ensure care plans remain current and effective.

The role includes telephonic, clinic, community, and home-based outreach as needed to support member engagement and successful resolution of identified needs.

In addition to providing direct care management, the Lead Care Manager provides day-to-day leadership and remote support to a team of Community Health Workers (CHWs) assigned to the provider practice(s). Responsibilities include managing patient assignments, providing coaching and case consultation, ensuring outreach and care coordination activities are completed, reviewing documentation for quality and completeness, and ensuring all billable services and interventions are accurately documented in both the provider's Electronic Health Record (EHR) and Ground Game.

Health's Implify platform. The Lead Care Manager monitors team productivity, quality, and performance metrics, supports staff development and workflow improvements, and ensures provider expectations, contractual requirements, and service level agreements are consistently achieved.

The Lead Care Manager partners closely with physicians, care teams, health plans, and community-based organizations to ensure coordinated, integrated care. The role participates in interdisciplinary care team meetings, communicates member progress and barriers, supports clinic workflows, and serves as the primary operational liaison between the provider…