Job Description

Zócalo Health
Remote + Field-based — Full Time, San Bernardino
Compensation: $90,000

About Us

Zócalo Health is a tech-enabled, community-oriented primary care organization serving people who have historically been underserved by the one-size-fits-all healthcare system. We partner with health plans, providers, and community organizations to deliver culturally competent primary care, behavioral health, and social care.

Our model is built for populations with high medical and social complexity, where fragmented care drives poor outcomes and unnecessary cost. We combine local, community-based teams with virtual care and modern technology to deliver coordinated, whole-person care where members live and receive support.

Founded in 2021, Zócalo Health is backed by leading healthcare and mission-aligned investors and is scaling rapidly across states and populations. We are building a durable care platform designed to perform in constrained healthcare environments and to lead the shift toward accountable, value-based care.

Our care model is designed to meet members wherever they are—whether in their homes, online, or in their community. Behavioral Health Case Managers are integral to our mission of providing culturally aligned and accessible care to the Latino community. They build trust through shared cultural and linguistic backgrounds, improving member engagement and access to care.

Zócalo Health is seeking a behavioral health case manager to serve as the primary point of contact for an assigned caseload of ECM members with behavioral health needs (including members with more complex mental health and/or substance use needs). This role provides relationship-based outreach, care navigation, care coordination, and brief skills-based behavioral health support to help members engage in appropriate services and move toward their goals.

Note: This role focuses on engagement, care coordination, brief interventions, and support strategies, including referrals and warm handoffs to psychotherapy, psychiatry, and Specialty Mental Health.

This position reports to the Senior Director of Clinical Operations. You will work primarily in your community, with some work-from-home responsibilities.

Responsibilities

Caseload Management and Member Engagement

• Manage an assigned caseload of ECM members with complex behavioral health needs, primarily Tier 1 and Tier 2 as defined by the organization's risk stratification framework. Conduct face-to-face visits at a frequency determined by the member's tier, with priority given to highest-acuity members.
• Serve as the primary relationship holder for members with behavioral health needs; provide consistent outreach, follow-up, and re-engagement support, including after ED or inpatient discharge when applicable.
• Maintain ongoing engagement with members both in-person and by phone, using evidence-based approaches such as motivational interviewing to promote collaboration between the member and the care team and to increase the member's sense of control over their whole health.
• Work with members to identify health and wellness goals and incorporate those goals into the member's shared care plan, facilitating communication among members, the care team, and external providers.

In-Person and Field-Based Care

• Conduct in-person home visits, community-based meetings, and field-based contacts as determined by member tier and clinical need.
• Conduct outreach (virtually and in-person) to members scheduled for appointments and complete initial intake and readiness-to-engage check-ins.
• Participate in community events to support member activation and trust-building, including relationship-building with key contacts, facilitating group education sessions, and liaising with community organizations.
• Attend and participate in community events as a Zócalo Health representative.

Brief Interventions and Clinical Support

• Utilize brief behavioral health therapeutic interventions as necessary to improve the member's ability to manage their own health, including behavioral activation strategies, coping skills coaching, and health literacy education related to behavioral health conditions and treatment options.
• Provide brief crisis support within scope and protocol (e.g., de-escalation and safety check-ins) and complete warm handoffs to local crisis resources or higher levels of care when indicated.
• Support individualized goal setting using motivational interviewing.

Education and Consultation

• Provide members and families with education on chronic medical and behavioral health conditions, treatment approaches, medications, and evidence-based practices to improve health literacy.
• Provide both formal and informal training and support to care team members on behavioral health conditions, including treatment approaches and evidence-based practices for care.
• Provide consultation for all care team members when discussing tasks of a clinical or behavioral health nature.

Care Coordination and Transitions of Care

• Coordinate access to behavioral health services, including referrals and warm handoffs to psychotherapy, psychiatry, and Specialty Mental Health.
• Assist with the coordination of medical and behavioral health access issues with PCP offices, specialists, and ancillary services.
• Assess for social determinants of health (SDOH) needs and enroll members in SDOH programs, including care planning development, referral to community resources, coaching, and graduation/transition planning.
• Ensure smooth transitions of care, including coordination with hospitals and facilities regarding member admissions and discharges.
• Coordinate internal clinical services.

Documentation, Assessment, and Outcomes

• Document all member and care team interactions accurately and in compliance with health plan standards.
• Track behavioral health outcome measures, required health assessments, and shared care plans in the care management platform; support the RNCM in review of health assessments and other care team documentation.
• Communicate member updates, barriers, and goals to the interdisciplinary team through case reviews and ad hoc consultations.

Team Collaboration

• Collaborate with a multidisciplinary care team to contribute to care plans, triage requests, and solve complex member needs.
• Play an active role in member registration and enrollment, including organizing community engagement and outbound outreach calls/texts.
• Provide social support by listening to member concerns and connecting them to appropriate support resources.

Qualifications

• Fluency (verbal and written) in English and Spanish.
• Knowledgeable of Latino customs and cultural norms (preferred).

• Master’s degree in Social Work

Licenses/Certifications (required)

• Active, unrestricted Clinical Social Work License (LCSW)

Experience

• 1–3 years healthcare experience or healthcare navigation within the community.
• Experience supporting members/patients with behavioral health needs (SMI/SUD exposure preferred).
• Familiarity with Google Workspace (preferred).
• Past experience documenting in an EHR (preferred).
• Training in motivational interviewing (preferred).

Preferred Qualifications

• Comfortable working with multiple computer applications simultaneously and willingness to learn new technologies and frameworks.
• Team player who builds effective working relationships.
• Ability to train others (preferred).
• Well-known in and have strong ties to the local Latino community (preferred).
• Well versed in local resources to support SDOH needs (preferred).
  
  

COVID-19 vaccination requirement

Zócalo Health requires all members of the care team to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

Flexible and able to travel to other communities

• Willing to travel to support community events and in person member appointments.
• Have reliable sources of transportation.
  
  

Benefits & Perks

• Ground floor opportunity; shape the direction of a fast-growing, high impact healthcare company
  Comprehensive benefits (medical/dental/vision)
• Generous home office stipend
• Competitive compensation
• Generous PTO policy including 6 paid holidays
  
  

You must be authorized to work in the United States. We are open to remote work anywhere in the locations outlined in this job description.

At Zócalo Health Inc., we see diversity and inclusion as a source of strength in transforming healthcare. We believe building trust and innovation are best achieved through diverse perspectives. Individuals seeking employment at Zócalo Health are considered without regard to race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.