PACE Behavioral Health Case Manager (National City, CA)

Position Summary:

Under the supervision of the PACE Director of Behavioral Health, the PACE Behavioral Health Case Manager is responsible for providing direct services and coordinating care for behavioral health participants with particular focus on those with complex needs. Specifically, the Case Manager works to ensure participants have access to and obtains the care and referral services needed to achieve and maintain optimal functioning, which will be through participation in PACE IDT meetings and working in close collaboration with the medical and BH teams. The Case Manager is responsible for providing case management, rehabilitative services, and outreach to participants of PACE. In collaborating with Behavioral Health providers, the Case Manager is responsible for developing an evidence- based, participant-centered treatment plan that supports the overall needs of participants. All Behavioral Health Case Managers will collaborate with IDT members, participate in team huddle meetings, treatment team meetings, conduct presentations, and abide by PACE policies and program funding contract requirements at all times.

Essential Functions of the Job:

• Provides direct services to participants, including case management, rehabilitative services, warm handoffs, referrals, and/or psycho-educational groups.
• Conducts comprehensive assessment of participants’ health and psychosocial needs, including health literacy status and deficits, and develops case management plan collaboration with the participant and family or caregiver in conjunction with Behavioral Health Clinicians and/or Primary Care Providers.
• Works collaboratively with other PACE Departments (e.g. Referrals, Social Services, etc.) to facilitate and monitor referral requests and processing to ensure timely receipt of services.
• Works closely with Behavioral Health Clinicians and PACE care teams including IDT meetings to identify participants who are eligible for services and in need of case management and rehabilitative services.
• Conducts phone follow ups to capture any potential participants previously referred by Primary Care Providers but that have not yet been scheduled with Behavioral Health.
• Represents San Diego PACE 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 participants.
• Conducts PACE assessments as requested.
• Maintains timely, complete, and accurate records with detailed assessment results, action plan, and progress notes. Clearly documents plans discussed with the participant, family or caregiver, Behavioral Health Clinicians, PCPs, Teams, 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 as required by CMS requirements and other various federal, state, and local programs.
• Provides outreach and collaborates with local community agencies to identify potential participants who may be eligible for behavioral health services and facilitates referral process.
• Maintains productivity of participant visits in accordance with clinic/program guidelines.
• Complies with established departmental and PACE program 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 home assessments may be required, and or meeting participants in the community based on need.

Additional Duties and Responsibilities:

• Begin developing the therapeutic alliance with participants by providing orientation to behavioral health services.
• Ensures that participants obtain necessary referrals to needed services as established in PACE care plans including but not limited to medication assistance, housing, mental health and substance abuse services, legal services, food assistance, etc.
• Maintains close contact with participants throughout their care. Identifies the reason for missed appointments, and assists participants in maintaining continuity of care with appropriate interventions.
• Educates participants, their families or caregivers, and IDT members 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 participants 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.

Job Requirements:

Education Required:

Bachelor's degree from a four-year college or university in psychology, social work, or related field.

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 1 year of experience providing case management services to a wide range of participant populations including (but not limited to) adults, youth, and their families.

Computer literacy required (i.e., proficient in word processing software, Microsoft Office, Excel, Electronic Medical Records software, etc.).

V erbal and Written Skills Required to Perform the Job:

Must possess excellent customer service, communication, and documentation skills with the ability to work cooperatively with other departments within a large community health center and satellite clinics. Must work well in a multi-disciplinary setting.

Technical Knowledge and Skills Required to Perform the Job:
Computer literacy required (i.e., proficient in word processing software, Microsoft Office, Excel, Electronic Medical Records software, etc.).

Equipment Used:

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

Working Conditions and Physical Requirements:

General office environment. Prolonged periods of sitting, and constant walking and standing. Occasional lifting, pushing, pulling up to 10 lbs. Driving to meet participants in the community, in-home assessments, and occasional travel required.

Universal Requirements:

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

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment. Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.