“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…