PACE Behavioral Health Case Manager (El Cajon, CA - Onsite)

• 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.

• 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.

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.