Lead Care Manager

Lead Care Manager (LCM) Position Description

Pay Range: $26–$36 per hourStatus: Full\-Time Reports To: Clinical Operations Manager in collaboration with the Programs Administrative ManagerLocation: Hybrid: Los Angeles County (office, community, telehealth)About the Therapeutic Play Foundation (TPF)

The Therapeutic Play Foundation is a Los Angeles–based nonprofit dedicated to building healthier communities through culturally responsive, trauma\-informed care. We integrate art, gardening, movement, collective care, and the Brain Well\-Being Model® to support families, youth, and adults in historically under\-resourced communities.

We provide services across:

• CalAIM Enhanced Care Management (ECM)
• Community Supports resource pathways
• Healthcare Access (psychotherapy \+ NP medical care)
• ArtGard™ \+ Collective Care™ programming
• Short\-Term Residential Therapeutic Program (STRTP)

Our model is collaborative, creative, and deeply community\-driven.

Position Summary

The Lead Care Manager (LCM) serves as the primary lead and central coordinator of client services within TPF’s interdisciplinary Support Squad model under the guidance of the Clinical Operations Manager and in collaboration with the Programs Administrative Manager. This position plays a critical role in coordinating whole\-person care for clients with medical, behavioral health, and social support needs through trauma\-informed, culturally responsive engagement and interdisciplinary collaboration.

LCMs maintain oversight of client care coordination activities, engagement workflows, transitions of care, assessment timelines, and interdisciplinary communication. This role works closely with Community Health Workers (CHWs), Medical Virtual Assistants (VAs), Clinical Consultants, Supervising Practitioners, STRTP staff, and administrative teams to ensure clients receive timely support, compassionate engagement, and access to healthcare and community\-based services.

The LCM is responsible for coordinating transitions of care for clients entering or exiting healthcare systems and higher levels of care, including clients recently discharged from hospitals, psychiatric facilities, crisis stabilization programs, skilled nursing facilities, incarceration settings, residential programs, shelters, detox facilities, or other institutional placements, consistent with ECM care coordination and DHCS transition of care expectations.

This role is ideal for someone who is organized, relationship\-focused, mission\-driven, and passionate about supporting community health through a collaborative and healing\-centered approach.

Key Responsibilities

Client Care Coordination \& Leadership:

• Serve as the primary lead and point of coordination for an assigned caseload of clients enrolled in ECM and/or Healthcare Access programs.
• Build strong, trusting relationships with clients and support them in navigating medical, behavioral health, and social service systems.
• Engage in regular, ongoing relationship building and client follow\-up activities each month.
• Maintain oversight of client engagement, service coordination, referrals, interdisciplinary communication, and continuity of care activities.
• Coordinate care across providers, community agencies, healthcare systems, and support programs to reduce barriers to care and improve health outcomes.
• Provide warm handoffs and support clients in connecting to medical care, behavioral health services, social services, housing resources, and community supports.
• Coordinate transitions of care for clients entering or exiting hospitals, emergency departments, psychiatric facilities, incarceration settings, residential programs, shelters, skilled nursing facilities, detox programs, or other care settings.
• Monitor transitions of care to prevent service gaps and support safe continuity of treatment and engagement.
• May participate in supportive engagement activities, interdisciplinary coordination, and wellness\-centered programming connected to TPF’s Short\-Term Residential Therapeutic Program (STRTP) based on organizational and client care needs.

Comprehensive Assessments \& Care Planning:

• Ensure the Wellness Pathway Form is completed and reviewed prior to onboarding clients into the Electronic Health Record (EHR) system, including EXYM.
• Complete, finalize, and maintain ECM Enrollment documentation, Comprehensive Assessments, and individualized Care Plans in collaboration with clients and interdisciplinary team members.
• Ensure Comprehensive Assessments are completed within forty\-five (45\) days of ECM enrollment.
• Ensure Care Plans and/or Treatment Plans are completed within sixty (60\) days of enrollment for ECM and Healthcare Access/Behavioral Health clients.
• Ensure care plans reflect client strengths, goals, identified barriers, wellness priorities, and interdisciplinary recommendations.
• Monitor and update assessments and care plans as clinically or operationally indicated.

Clinical Coordination \& Interdisciplinary Team Support:

• Coordinate with CHWs and Medical VAs who assist with outreach, scheduling, data gathering, LANES/PointClickCare review, and EHR support activities.
• Review measurement\-based care outcomes in Blueprint Health and communicate concerns, symptom changes, or elevated clinical needs to Clinical Consultants as appropriate.
• Maintain oversight of Blueprint Health screening tools and client\-reported outcomes to identify when additional clinical support or behavioral health intervention may be needed.
• Ensure Clinical Consultants and/or behavioral health providers are informed when clients may require clinical appointments, reassessments, crisis support, or additional interventions.
• Schedule and coordinate Multidisciplinary Team (MDT) meetings, clinical consultations, and interdisciplinary case discussions as needed.
• Communicate regularly with the Clinical Operations Manager and Clinical Consultants regarding client needs, safety concerns, barriers to care, or changes in functioning.

Wellness Engagement \& Community Programming:

• Facilitate or co\-facilitate monthly Wellness Labs grounded in the Brain Well\-Being Model® and Collective Care framework.
• Support culturally inclusive, trauma\-informed engagement across all client interactions and community programming.
• Send monthly e\-newsletters and wellness\-related updates to assigned clients regarding TPF programs, community events, and available resources.

Documentation \& Compliance:

• Maintain timely, accurate, and audit\-ready documentation within organizational systems and electronic health records.
• Complete outreach notes, case management documentation, care coordination activities, assessments, and care plans in accordance with organizational policies, HIPAA standards, and ECM/behavioral health program requirements.
• Track referrals, authorizations, outreach efforts, and client engagement activities to support compliance and continuity of care.

Physical Requirements:

• Ability to lift and carry approximately 15–25 pounds, with or without reasonable accommodation, to support community outreach activities, including transporting outreach materials, supplies, and equipment to and from outreach events and community sites.

Qualifications

• Experience in case management, care coordination, social services, health navigation, behavioral health, or a related field (minimum 1 year preferred).
• Familiarity with Medi\-Cal populations, CalAIM, Enhanced Care Management (ECM), transitions of care, or community\-based healthcare systems preferred.
• Strong communication, organization, relationship\-building, and documentation skills.
• Ability to complete documentation and required paperwork in collaboration with and on behalf of clients in a timely manner.
• Comfortable navigating Electronic Health Record systems, data platforms, and healthcare technology systems.
• Ability to work independently while thriving in a collaborative interdisciplinary care model.
• Trauma\-informed, culturally responsive, and community\-centered approach required.
• Bilingual Spanish/English strongly preferred.
• Technology savvy with proficiency in EHR systems, Google Workspace, Slack, and related platforms.
• Valid driver’s license preferred for field engagement and community\-based services.

Why Work With Us?

• A mission\-driven team committed to community healing and collective care
• Creative, wellness\-centered programming grounded in art, gardening, movement, and play
• Opportunities for growth in CalAIM, behavioral health, and integrated care coordination
• Supportive interdisciplinary team with weekly case huddles and clinical collaboration
• Hybrid schedule with meaningful field\-based work and community engagement
• Wellness culture that values staff whole\-person well\-being

Work Environment

• Full\-time hybrid role consisting of community\-based work, office\-based assignments, and telehealth coordination.
• This position may include virtual work assignments; however, in\-person attendance may be required based on operational needs, client engagement needs, field\-based services, meetings, Wellness Labs, outreach activities, trainings, interdisciplinary care coordination, or other organizational priorities as determined by management.
• Full\-time staff are expected to maintain availability during scheduled working hours and demonstrate flexibility and responsiveness to evolving client care and program needs.
• Some evening or weekend availability may occasionally be required for Wellness Labs, outreach events, transitions of care support, or community programming.
• Must be comfortable working in a fast\-paced, evolving CalAIM and community healthcare environment.
• Flexibility, communication, professionalism, and responsiveness to interdisciplinary team coordination are essential components of this role.

Pay: $26\.00 \- $36\.00 per hour

Work Location: Hybrid remote in Los Angeles, CA 90043