Behavior - RN/PHN Case Manager

The Public Health Nurse Behavioral Health Case Manager functions as an integral member of our PCMH-centered multi-disciplinary care team and implements utilizes the SDCHC universal screening tool to asses and create individualized self-care plans with patients. The Public Health Nurse BH Case Manager systematically identifies vulnerable patients with higher unmet needs and plans, manages, and coordinates care that will improve health outcomes through whole-person care planning. 

The role also includes supporting the clinical implementation of the SAPTA (Substance Use Prevention, Treatment, and Recovery Services) grant through direct patient care, assessment, and data collection for required IHS reporting.

Essential Duties and Responsibilities:

Primary Functions:

Patient Case Management

1. Prioritize care needs with patient collaboration to develop a written care plan that incorporates patient preferences and functional lifestyle goals, identifies treatment goals, addresses potential barriers, and produces a self-management plan.
2. Set attainable goals using evidence-based practice as the foundation while addressing gaps and/or barriers to care.
3. Make outbound calls to assess member health status and identify gaps or barriers in treatment plans.
4. Provide members with education to assist with self-management goals.
5. Make referrals to outside sources.
6. Educate members on disease processes or acute conditions.
7. Coordinates and attends member visits with the behavioral health team and specialists as needed in special circumstances.
8. Seeks ways to improve job efficiency and makes appropriate suggestions following the appropriate chain of command.
9. Adheres to organizational and departmental policies and procedures.
10. Coordinate care with the medical team/PCP and the medical case manager as appropriate
11. Attends educational offerings to keep abreast of change, comply with licensing requirements, and assist in the growth and development of associates by sharing knowledge with others.
12. Perform comprehensive assessments and document findings in a concise/comprehensive manner that is compliant with documentation requirements.
13. Other duties as assigned by the Behavioral Health Director.

Substance Use Prevention Treatment and Recovery Services (SAPTA) Clinical Responsibilities

1. Conduct patient screenings during BH intake using the SDCHC Universal Screening Tool, including PHQ-9, C-SSRS, AUDIT-C, SBIRT, and ACES.

2.   Identify and document patient needs related to substance use and incorporate findings into care plans.

3.   Provide direct clinical services aligned with SAPTA’s objectives, including prevention, early intervention, treatment coordination, and recovery support.

4.   Collect and track clinical data generated through assessments and patient care to fulfill SAPTA reporting requirements.

5.   Collaborate with the Grant Writer to ensure accurate and timely submission of required data through the IHS data collection portal.

6.   Monitor patient progress and outcomes related to SAPTA services, updating care plans in coordination with the BH team.

7.   Work closely with behavioral health providers and clinic staff to ensure SAPTA services are integrated into clinic workflows.

8.   Maintain full compliance with data privacy, reporting standards, and SDCHC protocols.

9.   Other SAPTA-related clinical duties as assigned.

Required Qualifications:

1. Current CA Registered Nurse (RN) license in good standing.
2. 1-year of case management experience.
3. Knowledge of available community-based social support services in the area

Education and/or Experience:

1. Bachelor’s degree in nursing from a four-year college or university (RN).

Preferred:

1. Experience serving a multinational, multicultural population.
2. Familiarity with Community Health Clinics and/or Indian Health Clinics.
3. Experience with EHR systems (e.g., ECw is a plus).
4. Bilingual in Spanish/English a plus.

Special Conditions of Employment:

1. Has a clean driving record and insurance as required by the state.
2. Has reliable transportation.
3. CPR/ BLS certification: Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization. Certification must include an in-person, hands-on skills assessment. Online-only certifications are not accepted.
4. Annual background checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
5. For-Cause Drug Screening: Comply with drug screening requirements when initiated by the organization for cause, to support a safe, compliant, and drug-free workplace.
6. Ongoing Compliance Requirements: Maintain up-to-date compliance with all required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and mandatory regulatory trainings as assigned by the San Diego Community Health Center (SDCHC).

Knowledge, Skills, and Abilities:

1. Able to communicate professionally in person and in writing.
2. Excellent oral and written communication skills.
3. Excellent time management skills
4. Excellent organizational skills and attention to detail.
5. Ability to maintain confidentiality and meticulous records.
6. Effective interpersonal skills.
7. Able to deal effectively with a diversity of individuals.
8. Ability to establish and maintain cooperative working relationships with all during work.
9. Must be reliable and trustworthy.
10. Proficiency in Microsoft Suite or related programs.

Physical and Mental Requirements:

1. Able to lift/move up to 40 pounds, move from place to place.
2. Able to sit at a desk and work on a computer for prolonged periods.
3. Able to stand, bend and reach for prolonged periods.
4. Ability to do math, organize and prioritize workload, work effectively and efficiently under stress.
5. Ability to supervise, multitask, understand, and follow instructions.
6. Ability to proficiently read, write, speak, and understand English.

Customer Service:

1. Actively supports, promotes, and works to fulfill the Mission, Vision, and core values of SDCHC.
2. Provides excellent internal and external customer service.
3. Demonstrates SDCHC’s Standards of Customer Service Behavior: Compassion, Attitude, Communication, Appearance, Sense of Ownership, and Teamwork.
4. Participate in ongoing customer service training.
5. Every action seeks to promote SDCHC as a top service organization.

Quality Management:

1. Contribute to the organization's success by participating in quality improvement activities.
2. Complies with all SDCHC policies and procedures and proactively participates in implementing new initiatives.
3. Participate and ensure continuous quality improvement process as directed by clinic leadership.  

Safety:

1. Ensures regulatory compliance and adherence to policies and procedures related to safe work practices.
2. Participate in infection prevention through appropriate use of infection control measures during patient treatment and patient interactions.
3. Ensure compliance with regulatory requirements for maintaining physical spaces, equipment, and supplies.  
4. Uses all appropriate equipment and/or tools to ensure workplace safety. 
5. Immediately reports unsafe working conditions. 

Privacy/Compliance:

1. Maintains privacy and security of all patients, employees, and volunteers' information and access to such information. Such information is accessed on a need-to-know basis for business purposes only. 
2. Compliance with all regulations regarding corporate integrity and security obligations. Reports on unethical, fraudulent, or unlawful behavior or activity.
3. Upholds strict ethical standards.

Flexibility:

Available for all shifts and, when required, can work evenings and weekends.

Disclaimer:

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.  This description reflects management’s assignment of essential functions.  It does not prescribe or restrict the tasks that may be assigned.  This job description is subject to change at any time.

Preference is given to qualified American Indian/Alaskan Natives under the American Indian Preference Act (Title 25, U.S. Code Section 472, 473, and 473a). Besides the above, the San Diego Community Health Center is an equal-opportunity employer.

Acknowledgement:

San Diego Community Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, gender identity, gender expression, ancestry, age, marital status, physical or mental disability, or any other protected class, political affiliation, or belief.

Preference is given to qualified American Indian/Alaskan Natives in accordance with the American Indian Preference Act (Title 25, U.S. Code Section 472, 473 and 473a). In other than the above, the San Diego American Indian Health Center, is an equal opportunity employer.

San Diego American Indian Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, gender identity, gender expression, ancestry, age, marital status, physical or mental disability or any other protected class, political affiliation, or belief.