Lead Care Manager (LCM) - Bilingual (Hmong/English)

GroundGame.Health; Fresno (CA); On-site; USD 70,000 - 85,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

Life and disability insurance

Job summary

GroundGame.Health is seeking a Lead Care Manager in Fresno, CA to identify, enroll, and support members in CalAIM ECM, CHI, and CHW programs. You will integrate social care into clinical settings, ensure timely assessments, coordinate care, and connect members with healthcare and community resources.

You will lead a team of CHWs, provide coaching, monitor performance, and ensure compliant documentation across EHR and Implify platforms. Onsite presence is required in the Fresno area.

Qualifications

• CHW Certification required or 2+ years in care coordination.
• EMR systems experience required.
• Willingness to travel between locations and patients' homes.
• On-site work in provider clinics and patients' homes.
• Bilingual in English and Hmong.

Responsibilities

• Identify and engage members in CalAIM ECM, CHI, CHW and related programs.
• Provide care coordination, assessments, and referrals.
• Lead a team of CHWs, coach and review documentation.

Skills

EMR experience

Travel readiness

Driver's license

Bilingual English/Hmong

On-site work

Education

CHW Certification

Bachelor's degree preferred

Tools

Implify platform

Job description

GroundGame.Health ~ Connecting the Unconnected to Close Health Equity Gaps

At GroundGame.Health, our mission is to improve lives by bridging the gap between clinical care and community support. We foster a collaborative, mission-driven culture where every team member plays a vital role in helping members overcome barriers, achieve better health outcomes, and thrive. We are committed to innovation, accountability, integrity, and excellence while empowering our employees to make a meaningful difference in the communities we serve.

We are a technology-enabled care management organization dedicated to improving health outcomes by addressing the social and health-related needs that impact people's well-being. We partner with health plans, provider organizations, and community-based organizations to deliver person-centered care coordination, Enhanced Care Management (ECM), Community Health Integration (CHI), Community Health Worker (CHW), and other value-based care services that improve access to care and reduce health disparities.

Our multidisciplinary teams work alongside providers to identify and address Health-Related Social Needs (HRSNs) and Social Determinants of Health (SDOH), connecting members with healthcare, community resources, and social services that support healthier lives. By combining compassionate, trauma-informed care with innovative technology and data-driven insights, we help ensure every member receives coordinated, equitable, and high-quality care.

About the Role

We are seeking a compassionate, driven Lead Care Manager to identify, engage, enroll, and support members participating in CalAIM Enhanced Care Management (ECM), Community Health Integration (CHI), Community Health Worker (CHW) services, or other care coordination programs. This role is embedded within one or more provider practices, serving as an extension of both the provider office and GroundGame.Health. As the primary liaison between physicians, clinical staff, patients, and the GroundGame.Health care management team, you will integrate social care into the clinical setting by identifying patients with health-related social needs and ensuring they receive timely assessments, care coordination, case management, and connections to healthcare, community, and government resources.

Using trauma-informed, culturally responsive, and person-centered practices, you will build trusting relationships with members and their support systems, educate members on available services, obtain required consents, and provide ongoing support throughout program participation. You will conduct comprehensive Health-Related Social Needs (HRSN) and Social Determinants of Health (SDOH) assessments, identify barriers related to housing, food insecurity, transportation, financial hardship, behavioral health, healthcare access, and other social needs, develop individualized care plans in collaboration with members and interdisciplinary care teams, coordinate referrals, support healthcare navigation and appointment scheduling, monitor referral outcomes, and reassess members throughout enrollment to ensure care plans remain current and effective. The role includes telephonic, clinic, community, and home-based outreach as needed to support member engagement and successful resolution of identified needs.

In addition to providing direct care management, the Lead Care Manager provides day-to-day leadership and remote support to a team of Community Health Workers (CHWs) assigned to the provider practice(s). Responsibilities include managing patient assignments, providing coaching and case consultation, ensuring outreach and care coordination activities are completed, reviewing documentation for quality and completeness, and ensuring all billable services and interventions are accurately documented in both the provider's Electronic Health Record (EHR) and GroundGame.Health's Implify platform. The Lead Care Manager monitors team productivity, quality, and performance metrics, supports staff development and workflow improvements, and ensures provider expectations, contractual requirements, and service level agreements are consistently achieved.

The Lead Care Manager partners closely with physicians, care teams, health plans, and community-based organizations to ensure coordinated, integrated care. The role participates in interdisciplinary care team meetings, communicates member progress and barriers, supports clinic workflows, and serves as the primary operational liaison between the provider practice and GroundGame.Health.The onsite location is in Fresno, CA.

The Lead Care Manager is responsible for maintaining accurate, timely, and compliant documentation of member interactions, assessments, care plans, referrals, interventions, and services rendered in accordance with HIPAA, CMS, CalAIM, payer, and organizational requirements. The role supports quality assurance initiatives, audit readiness, regulatory compliance, and continuous process improvement while managing assigned caseloads through EMRs, Implify, and referral management platforms. Additional responsibilities include monitoring tasks and referrals to ensure timely completion, supporting implementation of care management initiatives, and performing other duties as assigned in support of high-quality, person-centered care.

Required Qualifications

Community Health Worker (CHW) Certification or a minimum of two (2) years of experience in care coordination, case management, community health, healthcare outreach, patient navigation, social services, Community Health Worker services, or related healthcare roles.

• Experience utilizing Electronic Medical Records (EMRs).
• Reliable transportation and the ability to travel between assigned work locations and patients' locations.
• Valid driver's license and acceptable driving record.
• Ability to work onsite within assigned provider clinics, healthcare facilities, and patients' homes.
• Bilingual in English and Hmong.
• Must be willing to adhere to all provider practice dress code, infection prevention, and safety protocols while working in clinical settings. This includes compliance with facility-specific requirements such as health screenings, tuberculosis (TB) testing, immunization and vaccination requirements, personal protective equipment (PPE) policies, and other occupational health and safety standards as required by the provider practice or applicable regulations.

Preferred Qualifications

• Bachelor's degree preferred in Social Work, Human Services, Public Health, Healthcare Administration, Nursing, Psychology, Sociology, Community Health, Behavioral Health, or a related field.
• Community Health Worker (CHW) Certification.
• Experience supporting CalAIM, Enhanced Care Management (ECM), Community Health Integration (CHI), Community Supports, care management, or population health programs.
• Comprehensive Health: Medical, dental, and vision insurance coverage.
• Income Protection: Life and disability insurance plans included.
• Annual Base Salary: $70,000 - $85,000 (Depending on experience and qualifications)