Description

POSITION OVERVIEW:

The Peer Case Manager is an important role within the Certified Community Behavioral Health Center at La Familia. This program will provide a whole-person integrated care model of behavioral health and social service navigation, with strong coordination with primary health, in order to improve related outcomes in Alameda County. The Peer Case Manager will provide direct service to participants, providing either solution-focused short-term support or longer case management support, based on an assessment and services plan, and will also support the design and implementation of outreach and community engagement activities. This role will uphold and champion the agency’s mission, vision, and values and contribute to a collaborative and inclusive work culture.

Essential Job Functions and Responsibilities:

Case Management and Individualized Care Coordination

• Manage a caseload of clients to provide and track case management and care coordination services, including:
  • • Develop and maintain rapport with participants and maintain rapport and trust through consistent, regular meetings, including proactively communicating and soliciting updates from participants and consistent use of Motivational Interviewing techniques.
    • Provide timely, thoughtful, trauma-informed, culturally responsive responses to participants and all partners.
    • Conduct initial assessments and work with the clinical consultant team and supervisor to finalize each assessment.
    • Help participants identify and remain engaged with personal motivation towards case plan objectives.
    • Facilitate the planning process of an individual's case plan; oversee, evaluate and monitor the implementation of case plan objectives.
    • Provide outreach engagement, linkage, and follow up services to clients.
    • Act as a role model, with the intention of inspiring, engaging, and advocating for client’s wellness and rights.
    • Research and provide referral resources for participants in order to help them meet their needs.
    • Support participant’s through transitions of care, including but not limited to hospital discharge and moving to higher or lower levels of care with a new service provider, including helping participants to access timely information, determine options, set criteria for choices, and provide information to all providers.
    • Provide crisis intervention as needed, including de-escalating and stabilizing clients in crisis through brief intervention and escalating support for the client to clinical consultants and other available interventions. 

Short Term Care Coordination and Follow Up

• Act as a member of the care team, including helping participants to create plans and strategies to overcome barriers to accessing care identified by other team members.
• Help participants make and access appointments with preferred partners.
• Make reminder calls and follow-up calls to verify participation or appointment attendance, as required. 

Community Engagement and Outreach 

• Design, implement, and track activities hosted at the CCBHC site and in the community, that result in community members feeling:
  • • More likely to access clinical services at the CCBHC
    • Validated about their stressors and able to identify others in the community who experience the same thing to build relationships
    • Supported and inspired to implement non-clinical wellness habits and activities in order to manage their own mental health 
    • Educated about mental health wellness for themselves and their family members and resources to reduce social service needs that contribute to stress or create barriers to accessing mental health care.
    • Confident in their ability to navigate and advocate.
    • Engaged as community stakeholders and advisors in the services and models of the CCBHC. 

• Provide effective outreach and timely response to engage all referrals made by funder and social service partners, including attending health fairs, making community presentations, etc.
• Maintain networking and referral relationships with relevant social service partners and other service providers.

Other:

• Provide complete and thorough documentation, include required forms and participant progress notes, and enter into Salesforce database.
• Maintains all records in accordance with funder and program requirements.
• Attend individual and team meetings as assigned. 
• Collaborate with evaluation team, as appropriate. 
• Attend trainings, monitor trade publications, and participate in events relevant to key responsibilities.
• Track and regularly report on key metrics for responsible function areas. 
• Leads and collaborate on special projects related to agency objectives as appropriate.
• Other miscellaneous duties as appropriate

Qualifications