Master of Social Work (MSW)

“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 towards 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. IF currently has 13+ facilities with 22+ micro-communities scattered across Orange County, Los Angeles County and the Inland Empire.

Role

The Behavioral Health Worker supports Illumination Health + Home’s Enhanced Care Management

(ECM) program in the Riverside region through community-based behavioral health engagement,

screening support, referral coordination, and follow-up for members with mental health, substance

use, and complex social needs. The position works within the multidisciplinary ECM team and

supports the assigned Lead Care Manager (LCM), who retains responsibility for overall member care

coordination and the Care Management Plan.

This is a non-clinical coordination role unless the employee holds additional credentials and is expressly

authorized to perform clinical functions. The role does not independently diagnose, provide

psychotherapy, or make clinical treatment decisions.

Pay range from $72,000 - $79,040 per year.

Schedule is Monday - Friday from 8:30am - 5pm.

Responsibilities

Behavioral Health Engagement

• Build trusting, culturally responsive relationships through trauma-informed, person-centered engagement and motivational interviewing.
• Conduct in-person member visits at shelters, housing sites, healthcare facilities, and other appropriate community settings in Riverside County; use phone or telehealth when appropriate.
• Identify barriers to treatment, including transportation, housing instability, access to providers, and difficulty navigating services.
• Coordinate with the LCM to re-engage members with unmet behavioral health needs and document outreach and outcomes.

Behavioral Health Screening and Clinical Escalation

• Assist with approved behavioral health screening and monitoring, including PHQ-9 and Brief Addiction Monitor (BAM), only when trained and authorized.
• Communicate concerning screening findings, deterioration, substance-related risks, and other changes promptly to the LCM and appropriate licensed practitioner.
• Follow IHH crisis and emergency procedures for imminent safety concerns; do not independently diagnose or determine treatment.
• Support measurement-based care by tracking assigned follow-up activities and communicating changes in member functioning and needs.

Care Coordination and Referral Follow-Up

• Coordinate referrals and warm handoffs to outpatient mental health, psychiatry, specialty mental health, Drug Medi -Cal/SUD services, crisis resources, and community supports.
• Track referrals through appointment scheduling, linkage, follow-up, or documented barriers and report gaps to the LCM.
• Collaborate with the LCM on behavioral health goals in the member’s Care Management Plan and support monthly updates and changes in status.
• Assist with transitions after ED visits, hospitalization, psychiatric care, or detoxification; coordinate with the LCM on required post-discharge follow-up.

Multidisciplinary Team Collaboration

• Participate in regular multidisciplinary team conferences, case discussions, practice coaching, and coordinated service planning.
• Work with nurses, medical providers, LCMs, community health workers, and external behavioral health providers while respecting role boundaries.
• Provide community-based, in-person availability within the contracted Riverside service region.

Documentation and Encounter Compliance

• Document each ECM service, outreach attempt, referral, and follow-up accurately in the designated care management documentation system (CMDS) or approved alternative.
• Submit timely documentation for encounter reporting; every ECM service must be reported using the appropriate applicable HCPCS code and staff classification.
• Coordinate with the LCM to support at least two qualifying ECM services per enrolled member per calendar month; this is a team-level engagement requirement, not two behavioral-health visits by this worker.
• Follow privacy and consent rules, including HIPAA, California confidentiality laws, and 42 CFR Part 2 where applicable.
• Maintain accurate records supporting audit readiness, service quality, and non-duplication of care management services.

Expectations

• Maintain professionalism, confidentiality, respectful communication, and sound judgment in all member and partner interactions.
• Provide primarily in-person, community-based support and maintain availability within the Riverside region.
• Escalate urgent safety concerns immediately and other significant clinical concerns promptly to licensed staff.
• Complete assigned service documentation within 24–48 hours under IHH internal expectations; follow any shorter applicable plan deadlines.
• Participate in required program webinars, monthly practice coaching, and semiannual learning sessions.
• Complete care management documentation system introductory training within 30 business days of hire when applicable.
• If classified as a Community Health Worker on the ECM care team, complete the required nine-week CHW curriculum or an approved equivalent.
• Support continuous improvement, reliable referral follow-up, and timely communication with ECM leadership.
• We uphold the values of Community, Action, Respect, and Empowerment in all aspects of our work.
• Community

We lead with the vision of a strengthened and compassionate community for all. By embodying collective care, we serve as an example of what is possible when we come together.

• Action

Our “whatever it takes” mindset drives us forward. We take initiative, step in where others have stepped out, and create solutions when none exist.

• Respect

We deeply value the dignity and uniqueness of every individual we serve. We honor their stories, their journeys, and their right to be seen and heard.

• Empowerment

We heal - always. Our work enables clients to grow stronger in health, confidence, and belief in their potential as they move forward on their life journey.

Preferred Experience/Minimum Qualifications

Required

• Master of Social Work (MSW) degree from a CSWE-accredited program strongly preferred; active California Associate Clinical Social Worker (ASW) registration with the Board of Behavioral Sciences highly desirable.
• At least two (2) years of experience providing behavioral health support, case management, community-based outreach, care coordination, or related direct services to individuals with complex health and social needs.
• Demonstrated knowledge of mental health and substance use disorders, behavioral health treatment and referral pathways, trauma-informed care, crisis recognition and escalation, confidentiality requirements, and professional scope of-practice boundaries.
• Ability to conduct regular in-person community visits throughout the Riverside service region; reliable transportation and ability to meet applicable driving requirements when driving is an essential job duty.
• Proficiency with electronic health records or care management documentation systems, timely case notes, referral tracking, and accurate service encounter documentation.
• Ability to work collaboratively with Lead Care Managers, nurses, licensed behavioral health providers, and community partners; willingness to complete required onboarding, screening-tool training, and ongoing program competencies.

Preferred

• MSW graduates eligible to pursue ASW registration are encouraged to apply. Any clinical duties assigned to an ASW require appropriate supervision, authorization, and compliance with California scope-of-practice rules.
• Experience with Medi-Cal, CalAIM ECM, homelessness services, serious mental health needs, substance use disorders, and behavioral health treatment coordination.
• Experience with PHQ-9, BAM, motivational interviewing, trauma-informed care, crisis identification, and multidisciplinary teams; CHW or peer support certification is a plus where relevant to the applicable staffing classification.
• Bilingual English/Spanish.

Benefits

• Medical Insurance funded by Illumination Health + Home (Kaiser and Blue Shield), depending on the plan
• Dental and Vision Insurance
• Life, AD&D and LTD Insurance funded 100% by Health + Home
• Employee Assistance Program
• Professional Development Reimbursement
• 401K with Company Matching
• 10 days vacation PTO/year
• 6 days sick PTO/year
• 10 days holiday PTO/year
• Potential eligibility for the Public Service Loan Forgiveness Program (PSFL) for federally qualified loans