Case Manager I

Under the direct supervision of the Director of Behavioral Health and Case Management or designee the Case Manager I provides comprehensive case management services for patients eligible for Enhanced Care Management (ECM) or Complex Care Management (CCM). This role supports patients with complex medical behavioral and social needs serving as a key member of the interdisciplinary care team.

This position upholds the organizations mission vision and values through excellence collaboration innovation respect commitment to the community accountability and ownership. The Case Manager I develops and implements individualized care management plans supporting patients across physical health mental health substance use disorders (SUD) community-based long-term services oral health palliative care social supports and social determinants of health. Essential ECM and CCM activities include patient outreach screenings comprehensive assessments preventative care care coordination advocacy health promotion crisis navigation transitional care and referral to community and social services.

DUTIES & RESPONSIBILITIES:

General Case Management Duties:

• Conduct outreach and engagement efforts to connect patients with ECM/CCM services. This includes and is not limited to in-person community based field visits
• Perform screenings and comprehensive intake assessments to determine patient needs and eligibility.
• Independently manage a caseload of patients within productivity standards.
• Develop implement and monitor patient goals and progress within individualized Care Management Plans (CMPs) in collaboration with patients providers social support networks and the interdisciplinary care team.
• Maintain up-to-date accurate documentation within the electronic health record (EHR) ensuring timely data collection and compliance with reporting and documentation requirements.
• Facilitate warm hand-offs and ensure closed-loop referrals to appropriate healthcare and social service providers.
• As a care team leader support patients in accessing and utilizing healthcare services including medical behavioral dental and substance use treatment preventive care and chronic disease management.
• Provide education and training on self-management skills to improve patient health outcomes.
• Assist patients in accessing public benefits (e.g. SSI CalFresh cash aid) and gathering necessary documentation. Facilitate referrals to Community Health Services when appropriate.
• Advocate for patient needs and assist in overcoming barriers to care including transportation and appointment scheduling.

Mental Health Crisis Navigation:

• Utilize de-escalation and Motivational Interviewing techniques to manage crisis situations effectively.
• Conduct risk assessments for patients experiencing acute mental health distress and coordinate with crisis response teams as needed.
• Provide supportive interventions to stabilize patients and facilitate engagement with appropriate mental health services.
• Maintain communication with emergency responders hospitals internal staff and behavioral health teams to ensure continuity of care.
• Offer psychoeducation to patients and their families on coping strategies and crisis prevention.
• Follow up with patients and their families to ensure they are receiving the appropriate level of care in a timely manner.

Group Facilitation and Support Services:

• Work collaboratively with behavioral health providers and/or medical providers to facilitate psychoeducational and support groups addressing topics such as chronic disease management mental health substance use recovery and social skills development.
• Provide patient-centered coaching and peer support in group settings to promote shared learning and self-efficacy.

Comprehensive Transitional Care:

• Coordinate hospital and institutional discharge planning as well as internal case management services ensuring seamless transitions between level of care needs.
• Develop and implement transition care plans including follow-up appointments medication reconciliation and adherence support.
• Work with community-based organizations to secure necessary post-discharge services and supports.
• Monitor patients post-discharge to prevent readmissions and improve long-term health outcomes.

Community Collaboration and Advocacy:

• Develop and maintain professional relationships with internal and external stakeholders to enhance care coordination efforts.
• Serve as a liaison between patients providers and community resources advocating for patient needs.
• Participate in interdisciplinary team meetings case reviews and collaborative problem-solving discussions.
• Stay informed of local and statewide policies affecting patient access to services and advocate for improvements in care delivery.

Compliance and Professional Development:

• Adhere to organizational privacy security and compliance policies including HIPAA and OSHA regulations.
• Engage in ongoing professional development through continuing education training and participation in relevant workshops.
• Provide feedback to help with refining program workflows policies and procedures as needed.
• Consistently adhere to and/or exceed Saluds communication guidelines and expectations with co-workers and patients.
• Perform under limited supervision with accountability
• Perform other duties as assigned.

MINIMUM QUALIFICATIONS:

• Education and Experience:
• Bachelors degree in Social Work Psychology or a related field and a minimum of six (6) months of experience in mental health services intensive case management or healthcare coordination; OR
• Associates degree and three (3) years of direct service experience in mental health community services healthcare coordination and/or case management; OR
• High school diploma or GED and a minimum of four (4) years of direct service experience in the above areas.

Certifications:

• Community Health Worker (CHW) certification is required or the ability to obtain certification within twenty-four (24) months of employment depending on assignment.

Knowledge and Skills:

• Strong knowledge of community resources and ability to build rapport with diverse patient populations.
• General understanding of the complex needs of families in our community
• Proficiency in time management with the ability to prioritize tasks based on urgency and meet department productivity standards.
• Competency in electronic health record (EHR) systems and data management. Knowledge of basic medical and psychiatric terminology preferred
• Excellent oral and written communication skills.
• Strong collaboration skills with interdisciplinary teams.

Experience (Preferred):

• Experience in crisis intervention behavioral health navigation and trauma-informed care practices
• Experience providing trauma-informed and diversity-informed mental health services to high-risk individuals caregivers and/or families.
• Bilingual in Spanish required; bicultural preferred.

Additional Requirements:

• Valid CA drivers license and clean driving record.
• Ability to travel between sites and perform duties in the field including a variety of community-based settings within Santa Cruz Monterey and San Benito counties if needed.
• Flexibility to work a variable schedule including evenings and weekends as needed.

SALARY & BENEFITS:

Salary Range: $33.37 - $40.56 per hour

Employment Type: Limited Term (4 - 6 months)

Benefits:

• Employees on temporary assignments are eligible for holiday pay and California sick pay both pro-rated based on hours worked.

**Salud is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex disability age sexual orientation gender identity national origin veteran status or genetic information. Salud is committed to providing access equal opportunity and reasonable accommodation for individuals with disabilities in employment its services programs and activities. To request reasonable accommodation contact the Salud Human Resources Department and **