Reproductive Mental Health Case Manager

Position Summary: Under the supervision of the Program Manager, the Reproductive Mental Health Case Manager is responsible for providing direct services and coordinating care for pregnant and postpartum patients in an integrated healthcare setting. Specifically, the Case Manager works to ensure patients have access to and obtains the care and referral services needed to achieve and maintain optimal functioning. The Case Manager is responsible for providing case management, rehabilitative services, and outreach to patients of SYHealth. In collaborating with Behavioral Health providers, the Case Manager is responsible for developing an evidenced- based, patient- centered treatment plan that supports the overall needs of patients. All Behavioral Health Case Managers will participate in team huddle meetings, treatment team meetings, conduct presentations, and abide by SYHealth policies and program funding contract requirements at all times. Essential Functions of the Job: Provides direct services to patients, including case management, rehabilitative services, warm handoffs, and/or psycho-educational groups. Works in coordination with CCBHC Medical Director, Program Manager, and staff to provide interdisciplinary care to pregnant and postpartum patients, including cases of pregnancy loss. Maintains communication with OB and primary care team, including pediatricians and infant care team as appropriate. 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. 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. Ensuring patients have access using in person and telehealth appointments. Represents San Ysidro Health 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 patients. Conducts GPRA assessments as part of CCBHC program. 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. Be the liaison and coordinate scheduling for Chronic Pain Management in Female Community Health Center Patients Grant. Funded by Office of Women’s Health (OWH). Maintains productivity of patient visits in accordance with clinic/program guidelines. Complies with established departmental and health center 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 field work is required, meeting patient in the community based on need. Additional Duties and Responsibilities Begin devel…