Position Summary:

Under the supervision of the Program Manager, the Behavioral Health Case Manager is responsible for providing direct services and coordinating care for behavioral health patients with particular focus on those with complex needs. Specifically, the Case Manager works to ensure patients have access to and obtains the care and referral services needed to achieve and maintain optimal functioning. The Case Manager is responsible for providing case management, rehabilitative services, and outreach to patients of SYHealth. In collaborating with Behavioral Health providers, the Case Manager is responsible for developing an evidenced- based, patient-centered treatment plan that supports the overall needs of patients. All Behavioral Health Case Managers will participate in team huddle meetings, treatment team meetings, conduct presentations, and abide by SYHealth policies and program funding contract requirements at all times.

Essential Functions of the Job:

• Provides direct services to patients, including case management, rehabilitative services, warm handoffs, and/or psycho-educational groups.
• Conducts comprehensive assessment of the patients’ health and psychosocial needs, including health literacy status and deficits, and develops case management plan collaboration with the patient and family or caregiver in conjunction with Behavioral Health Clinicians and/or Primary Care Providers.
• Works collaboratively with other SYHealth Departments (e.g. Referrals, Social Services, Health Education, etc.) to facilitate and monitor referral requests and processing to ensure timely receipt of services.

• Works closely with Behavioral Health Clinicians to identify patients who are eligible for services and in need of case management and rehabilitative services.
• Conducts phone follow ups to capture any potential patients previously referred by Primary Care Providers but that have not yet being schedule with Behavioral Health. Ensuring patients have access using in person and telehealth appointments.
• Represents San Ysidro Health and Behavioral Health Department to other organizations in order to create and maintain partnerships with other community programs to improve referral outcomes and quality of care towards patients.
• Conducts GPRA assessments as part of CCBHC program.
• Maintains timely, complete, and accurate records with detailed assessment results, action plan, and progress notes. Clearly documents plans discussed with the patient, family, Behavioral Health Clinicians, PCPs, etc. in the electronic health record system to ensure that communication is available to all team members.
• Assists in the preparation of monthly narrative and statistical reports covering progress toward meeting outcome and process objectives established in the Behavioral Health grant proposal and/or as required by various federal, state, and local programs.
• Provides outreach and collaborates with local schools and/or other community agencies to identify patients who are eligible for behavioral health services and facilitates referral process.
• Be the liaison and coordinate scheduling for Chronic Pain Management in Female Community Health Center Patients Grant. Funded by Office of Women’s Health (OWH).
• Maintains productivity of patient visits in accordance with clinic/program guidelines.
• Complies with established departmental and health center policies and procedures, objectives, quality assurance program, safety, environmental and infection control standards.
• Performs other related activities as required, assigned and/or requested.
• Some in field work is required, meeting patient in the community based on need.

Additional Duties and Responsibilities:

• Begin developing the therapeutic alliance with patients by providing orientation to mental health services.
• Uses IMPACT / ESBIRT model for treatment; coordinates patient care with Behavioral Health provider, Primary Care Physician, and psychiatrist via consultation, collaboration, follow up, and recommendations.
• Ensures that patients obtain necessary referrals to needed services as established in case plans including but are not limited to medication assistance, housing, mental health counseling, substance abuse counseling, legal services, food assistance, etc.
• Maintains close contact with patients throughout their care. Identifies the reason for missed appointments, and assists patients in maintaining continuity of care with appropriate interventions.
• Educates patients, their families or caregivers, and members of the health care delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, case management, etc. so that timely and informed decisions can be made.
• Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental and infection control standards.
• Attends meetings, trainings and community events as required and participates on committees as directed.
• Assists in monitoring the quality assurance and evaluation process ensuring that contract compliance and outcome and process objectives for patients and their families are met.
• Completes and submits required data entry and reports in a timely manner.
• Enhances professional growth and development through participation in educational programs, case conference or treatment team meeting presentations, current literature, in-service meetings and workshops.

Education Required:

Bachelor's degree from a four-year college or university in psychology, social work, or related field. If no Bachelor’s degree has been completed, a minimum of 2 years of fully relevant Behavioral Health Case Management experience will be considered.

Certifications/Licenses Required:

Valid CA Driver’s license and an appropriately insured personal vehicle. (Local travel to different sites is required.)

Experience and Required Skills:

• A minimum of one year’s experience providing case management services to a wide range of patient populations including (but not limited to) adults, youth, and their families.
• Ability to work cooperatively with other departments within a large community health center and satellite clinics.
• Works well in multi-disciplinary setting.
• Must possess excellent customer service, communication and documentation skills.
• Must write clearly and legibly.
• Computer literacy required (i.e. proficient in word processing software; Microsoft office; Excel spreadsheets); Electronic Medical Records software.

Verbal and Written Skills Required to Perform the Job:

Bilingual/Bicultural Spanish/English.

Equipment Used:

Computers, phones, vehicles, copy machines and fax machines etc.

Working Conditions and Physical Requirements:

Long irregular hours. May work weekends. Prolonged periods of sitting, and constant walking and standing. Driving to meet patients in the community and occasional travel required.

Working Conditions and Physical Requirements:

General office environment. Prolonged sitting. Occasional standing, walking, lifting, pushing, pulling up to 10 lbs. May drive around San Diego county for various meetings and trainings.

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs.