Case Manager

“Every person deserves compassion, dignity, and the safety of a place to call home.”

Homelessness is the largest social and public health crisis in California. Illumination Health + Home is a growing non‑profit organization dedicated toward disrupting the cycle of homelessness by providing targeted, interdisciplinary services in our recuperative care centers, emergency shelters, housing services and children’s and family programs. IHH currently has 13+ facilities with 22+ micro‑communities scattered across Orange County, Los Angeles County and the Inland Empire.

Job Description

The Care Coordinator is a site‑based, client‑facing role within Care Management, responsible for identifying, engaging, assessing, enrolling, and advocating for specific populations on a regular basis. This individual serves as the primary point of contact for clients who are intermittently housed with Illumination Health + Home. The Care Coordinator establishes strong relationships with clients to support their engagement in medical care, behavioral health services, and social support systems.

This role adopts a holistic, non‑clinical approach, emphasizing adherence to evidence‑based practices, understanding client and service barriers, and considering social determinants of health. The Care Coordinator facilitates appropriate coordination of services for targeted populations, assisting clients in navigating healthcare systems, promoting preventative care, and collaborating closely with the client’s Care Team. The schedule for this role is:
Tuesday – Saturday, 10:00 am to 6:30 pm
.

Client Needs:

• Provide comprehensive case management by assessing client needs, developing individualized treatment plans, monitoring progress, supporting clients, making appropriate referrals, and conducting follow‑up on weekly goals and action steps.
• Complete care plans and maintain accurate documentation within Electronic Health Records (EHR) and client databases (e.g., HMIS, Champ, or Health Plan programs, if applicable) using SMART format where appropriate.
• Collaborate with other departments by attending weekly meetings to evaluate program effectiveness, discuss client progress, and develop strategies to meet clients' needs and enhance treatment plans.
• Connect clients to resources that support their psychosocial and daily needs, including healthcare, nutritional assistance, hygiene supplies, and referrals to transitional or permanent supportive housing and other relevant service providers, such as primary care physicians and healthcare teams.
• Perform crisis intervention as necessary.
• Establish and maintain confidential case files for all participants and review required statistical reports for program management and evaluation purposes.
• Maintain communication with external agencies involved in client care.
• Promote awareness and understanding of monthly health promotion topics and materials.
• Accompany clients to medical appointments and coordinate transportation as needed.
• Manage a caseload of up to 30–35 ECM members, unless instructed otherwise by senior management within policy guidelines.
• Prepare for and participate in individual and group supervision sessions.
• Submit daily End of Shift (EOS) reports to document performance metrics.
• Compile and submit monthly tally sheets.

• Responsible for accurately recording all client interactions and content updates within Illumination Health + Home’s Electronic Medical Record (EMR), in accordance with organizational standards and contractual obligations.
• Progressively documenting all aspects of the client’s care plan, including achieved goals and upcoming objectives.
• Recording engagement levels, such as the frequency and duration of client encounters.
• Documenting evaluative client case details that inform decisions regarding referrals to alternative resources.
• Recording obtained client documentation, including vitals, insurance cards, SSI award letters, and other relevant records.
• Noting client disengagement and reintegration activities.
• Maintaining awareness of services offered by other providers in the network.
• Upholding strict confidentiality in compliance with agency policies.
• Managing…