Behavioral Health Care Manager – Street Medicine ECM

About Wellness Equity Alliance

Wellness Equity Alliance is a national multidisciplinary health organization that designs and delivers integrated, community-based care for populations most impacted by health inequities.

We do this through mobile and field-based models, providing medical care, behavioral health services, substance use treatment, harm reduction, and care coordination in nontraditional settings such as encampments, schools, reentry sites, and rural communities, as well as with sovereign tribal nations.

Grounded in trauma-informed, culturally responsive, and data-driven practices, WEA combines clinical expertise, lived experience, and advanced population health analytics to reduce barriers to care, improve continuity, and strengthen local systems.

We have partnered with more than 60 public agencies, managed care plans, and community-based organizations across the U.S. to implement scalable, sustainable programs that are advancing health equity and improving outcomes for historically marginalized populations.

We are known as Renegades, Rebels, Disruptors, and Dreamers. If that sounds like you, we want you on our team.

Position Summary

The Behavioral Health Care Manager is a specialized clinical and coordination role. It supports Medi-Cal members who have complex mental health, emotional, or substance use needs. The position serves as the ECM Lead Care Manager and provides high-touch, person-centered coordination.

The Care Manager works alongside street medicine clinicians and meets members face to face wherever they stay: encampments, vehicles, shelters, and provider offices. The role connects members’ primary care, specialists, and community resources, and supports each member from first contact through stable housing and connected care.

Location: Field-based across Riverside and San Bernardino Counties (encampments, vehicles, shelters, mobile unit)

Schedule: Monday–Friday, with occasional evening or weekend outreach

Population of Focus

Individuals experiencing homelessness who also have complex health needs. This includes adults, and families or unaccompanied youth where applicable. Many members also meet Serious Mental Health or SUD criteria.

Essential Duties and Responsibilities

Duties are organized around the seven ECM core service components. Every ECM provider must deliver all seven to every enrolled member.

Outreach and Engagement

Join the street medicine team on scheduled rounds to encampments, riverbeds, vehicles, parks, shelters, and drop-in sites to engage new members and re-locate existing ones.

Build trust over repeated contact using motivational interviewing, harm reduction, and trauma-informed engagement, recognizing that engagement may take many visits.

Coordinate with homeless outreach teams, shelters, and Coordinated Entry to locate members who move, and document every attempt, method, and location.

Help members without active coverage begin Medi-Cal enrollment, including Presumptive Eligibility where available.

Comprehensive Assessment and Care Management Plan

• Complete a whole-person field assessment covering physical health, mental health, SUD, oral health, and social drivers of health, including specific attention to housing needs.
• Screen for suicide, overdose, and medical risk, including exposure and wound concerns flagged by clinicians.
• Develop a person-centered care plan with housing goals and action steps, and update it as the member’s situation changes.

Enhanced Coordination of Care

Serve as Lead Care Manager and single point of contact among the street medicine clinicians, the PCP, county mental health and DMC-ODS, the managed care plan (MCP), and housing providers.

Link members to ongoing behavioral health and SUD treatment, including medications for addiction treatment initiated by the street medicine team.

Help members find providers and schedule primary and specialty care appointments, and arrange follow-up after hospital discharge.

Support adherence by replacing lost medications and IDs, sending reminders through any working channel, arranging transportation, and accompanying members to visits.

Health Promotion and Behavioral Support

Engage members in therapeutic interactions within scope of practice, such as motivational interviewing and brief supportive counseling, to promote healthy behaviors and recovery goals.

Support medication management by reviewing adherence, side effects, and refills with members and coordinating with prescribers. The Care Manager does not prescribe or change medications.

Coach members on managing health conditions while unsheltered.

Distribute naloxone and other harm reduction supplies according to agency protocol, and teach members how to use them.

Comprehensive Transitional Care

Respond to ADT notifications and locate members after ED visits, hospital discharges, psychiatric holds, jail release, or sobering center stays.

Coordinate discharges to Recuperative Care or other safe settings instead of the street whenever possible.

Member and Family Supports

• With consent, engage partners, family, and other chosen supports in the care plan.
• Serve families or unaccompanied youth as a unit where applicable.
• Coordination of and Referral to Community and Social Support Services
• Enter and update members in Coordinated Entry/HMIS and keep housing assessments current.

Refer to and coordinate Community Supports, including Housing Transition Navigation, Housing Deposits, Housing Tenancy and Sustaining Services, Transitional Rent, Recuperative Care, Sobering Centers, and Medically Tailored Meals.

Connect high-risk members directly to essential social services: food security (CalFresh, food banks, IEHP food distribution, and ConnectIE resources), childcare for parents, and benefits (SSI/SSDI, GA).

Help members obtain vital documents such as ID, birth certificate, and Social Security card.

Advocate with landlords, housing navigators, and property managers through move-in and early tenancy.

Depression Care Management

The Care Manager provides measurement-based depression care management for members who screen positive for depression. This work is done in partnership with the member’s PCP, street medicine clinicians, and psychiatric consultant.

Screen members at intake and periodically with the PHQ-2/PHQ-9, or with age-appropriate tools where applicable.

Respond the same day to any positive suicide item (PHQ-9 item 9) with a structured risk screen (e. g., C-SSRS), safety planning, and escalation per protocol.

Gather depression history, current treatment, medications, substance use, and stressors, and share results with the treating provider. The Care Manager does not diagnose.

• Set depression goals within the ECM care plan, including meaningful improvement or remission on the PHQ-9.
• Deliver or link members to brief evidence-based interventions within scope, such as behavioral activation, problem-solving, motivational interviewing, and psychoeducation.
• Refer members to therapy, psychiatry, county SMHS, or SUD treatment as severity indicates.
• Maintain a depression registry and bring members who are not improving to case review.
• Re-administer the PHQ-9 at regular intervals per program protocol and document scores in the designated care management system.
• Check in on medication adherence and side effects, and relay concerns to the prescriber.
• Escalate members whose scores are not improving or are worsening within protocol timeframes.
• For members who reach remission, develop a relapse-prevention plan and continue monitoring before stepping down care.
• Documentation, Billing, and Compliance

Document every ECM encounter and outreach attempt in the designated care management system to the standards set by the MCP contract and DHCS ECM reporting.

Record each outreach attempt, encounter, and core service component delivered, including date, mode (in person, telehealth, phone), and location, within program-required timeframes.

Complete assessments and care plans within the timeframes required by the MCP contract.

Enter accurate encounter and invoice data for ECM billing according to MCP specifications. Never bill for services that were not delivered.

• Track member authorization periods and request reauthorization or discontinuation on time.
• Share information only as permitted by HIPAA, 42 CFR Part 2, and member consent.
• Report incidents, grievances, and suspected abuse according to agency policy and mandated reporter law.
• Participate in MCP audits, chart reviews, and corrective action as requested.

Additional Responsibilities

Provide crisis intervention in the field within scope of practice and per agency protocol. This includes safety planning, warm handoffs to mobile crisis, and coordination around 5150 evaluations when indicated.

Coordinate with the team ahead of encampment resolutions or sweeps to protect members’ medications, documents, and continuity of care.

• Assess members’ readiness to graduate from ECM using the MCP’s approved criteria.
• Participate in team huddles, case conferences, clinical supervision, and MCP meetings.
• Perform other duties as assigned within the scope of ECM.

Working Conditions and Supervision

Fieldwork: Most of the workday is spent outdoors with the street medicine team in encampments, riverbeds, vehicles, parks, and shelters. Weather conditions include heat, cold, rain, and smoke. The role requires extended walking, carrying supplies, and working on uneven terrain. Reasonable accommodations are available for qualified individuals.

Supervision: Weekly individual supervision with the Director of Behavioral Health, daily huddles with street medicine clinicians, and clinical consultation for complex cases.

Qualifications

This is a master’s-level position. California licensure is not required.

Minimum Qualifications

Master’s degree in social work, counseling, marriage and family therapy, psychology, or a closely related behavioral health field.

Direct experience serving people who are unhoused or housing insecu