PACE Behavioral Health Case Manager (San Ysidro, CA)

• 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.

Universal Requirements:

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