Job description

Position Summary:
Under the supervision of the Program Manager, the Behavioral Health Case Manager Lead is responsible for coordinating the day-to-day activities of the behavioral health case management and designated behavioral health special programs including IMPACT/ ESBIRT, CCBHC, and Blue Shield projects. In addition, BH Case Manager Lead will oversee activities and workflows related to Grant Projects by Health Quality Partners which include: Office of Women’s Health- STOMP Program (Structuring your own management of pain) and SBIRT (SOS)- GPRA Screenings Project. The BH Case Manager Lead serves as liaison and point of contact for all case management and related outreach events for the behavioral health department. Champion providing direct services and coordinating care for behavioral health patients with particular focus on those with complex needs. Specifically, the Case Manager Lead works to ensure patients have access to and obtains the care and referral services needed to achieve and maintain optimal functioning. The BH Case Manager lead is also responsible for the coordination and tracking of external department referrals (e.g. 211 referrals, MHAT referrals, etc.). The Behavioral Health Program Coordinator will also provide direct services and coordinating care for behavioral health patients in the IMPACT/ESBIRT program. In collaboration with Behavioral Health Clinic Directors, is responsible for developing an evidenced-based, patient-centered treatment plan that supports the overall needs of patients. Meet with all department case managers on a monthly basis. Ensure all Behavioral Health Case Managers participate in supervision, attend treatment team meetings, conduct presentations, and abide by SYHealth policies and program funding contract requirements at all times.

Essential Functions of the Job:

• Oversee the day to day activities to BH Case Management Program providing guidance and support when needed. Additionally, will provide training, consultation, and problem solving assistance to Case Managers.
• Assists in creating case management templates

a.Assists with meeting block requests
b.Assists with time off block requests
c.Assists to open templates for new case managers

• Create training rotation for all case managers starting working in Department.
• 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.
• Participate in selective multi-disciplinary team meetings, treatment team meetings, monthly staff meetings, and selective staff development trainings.
• 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.
• 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.
• Assist in coordinating participation of BH Department in outreach events

a. Will create and maintain a tracking sheet with current data
b. Attend quarterly Outreach Meetings.

• Be a liaison for Behavioral Health in different areas, which can include but not limited to the following:

a. Collaborates and act as an active participant in identifying ways to improve overall Integration between Primary Care and BH by attending clinic’s treatment team and staff meetings
b. Point of contact for collaboration between Generate Hope and UCSD Psychiatry Fellows
c. 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 to ensure timely receipt of behavioral health services.

• Assist with new and intern orientation/ ESBIRT/ IMPACT training with BH Department.
• Provide direct services to eligible patients through ESBIRT/ IMPACT Program (County Grant), attend trainings and meetings as specified in grant

a. Meet with Promotora(s) in a monthly basis to coordinate services for patients referred to ESBIRT/IMPACT Program

• 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.
• Coordinates and arranges services for patients referred by 211/ Social Services.
• Coordinates and arranges services for patients referred by MHAT Grant.
• Coordinates and arranges services for patients referred by Youth Enhancement Program (YES).
• Coordinates and arranges services for patients referred by Health Education Department.
• Create, maintain and update case management related workflows which include the following:

a.MHAT Referrals
b.211 Referrals Workflow
c.OWH- STOMP Grant
d.SBIRT SOS- GPRA Grant
e.Case Management Referrals Workflow
f.Higher Level of Care Referrals Workflow
g.Warm Handoffs Workflow
h.Internal Referrals Workflow
i.Other: As needed.

• Oversee county grants:

a. OWH- Stomp Grant
i.Set up structure for program
ii.Coordinate with Clinic Services Managers for meeting location and dates
iii.Make sure program is meeting expectations
iv.Attend trainings/ meetings as requested by grant
b. SBIRT SOS- GPRA Grant
i.Arrange and train new personnel on GPRAs Screenings
ii.Provide coverage as needed
iii.Make sure Case Managers have resources to conduct screenings in a confidential matter
iv.Mare sure program is meeting expectations
v.Attend trainings/ meetings as requested by grant

• Assist with linkage for Blue Shield Grant (Partnership between San Ysidro Health Center and Maria Sardinas Wellness Recovery Center).
• Participate in ongoing staff development and initiate educational opportunities to maintain current knowledge of integrated case management services, behavioral health outreach and treatment specific resources.

Additional Duties and Responsibilities:

• Maintains productivity of patient visits in accordance with clinic/program guidelines.
• 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.
• Complies with established departmental and health center policies and procedures, objectives, quality assurance program, safety, environmental and infection control standards.
• 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.
• Effectively utilizes knowledge of resources available in the community in supporting the patient care plans.
• 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.
• Performs other related activities as required, assigned and/or requested.

Job Requirements: Education Required (Minimum level of education):
Bachelor's degree from a four-year college or university in psychology, social work, or related field; 1-2 years of previous experience in case management; linking patients/clients with various community resources preferred.

Preferred:
Working on a Master’s degree in Social Work or in Psychology.

Certifications/Licenses Required:
Valid CA Driver’s license

Experience Required (Minimum level of experience):
A minimum of 2-3 years of experience providing case management services to a wide range of patient populations including (but not limited to) adults, youth, and their families.

Verbal and Written Skills Required to Perform the Job: Bilingual/Bicultural Spanish/English preferred.

Other Requirements:

• 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

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

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.

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.

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