Behavioral Health Case Coordinator

    • Job Tracking ID: 2021-923
    • Job Location: Petaluma , CA
    • Job Level: Mid Career (2+ years)
    • Level of Education: Any
    • Job Type: Full-Time/Regular
    • Date Updated: October 06, 2021
    • Years of Experience: Up to 2 Years
    • Starting Date: ASAP
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Job Description:


Summary: The Behavioral Health Case Coordinator will provide high-quality psychological services in an integrated care sitting while coordinating care and services for patients in collaboration with the primary care, behavioral health care, and wellness teams.  Partner as a flexible member of the multidisciplinary healthcare team to provide seamless care for patients. This position support enhanced care coordination, population health and quality of care for patients receiving behavioral health and/or wellness services. This position also utilizes psycho-social skills to facilitate the coordination of care through assessment, planning, intervention, and evaluation.  The position ensures patients receive high-value care and archives optimal health outcomes.  This position promotes patient engagement, manages workflows and schedule management to enhance quality and integration of care. 

 Areas of Responsibility:

      Clinical Coordination

  • Engage in timely, patient-centered care planning, care plan implementation, and care monitoring
  • Coordinate care to promote proper care access and care continuity especially during transitions of care.  Care may address the individual health, behavioral or social needs of the patients. 
  • Recommend supportive and therapeutic interventions as indicated to ensure optimal patient outcomes.
  • Assess and document in EHR patient/family needs and collaborates with care team to identify possible psychosocial related needs
  • Collaborates with RN Case Managers and care teams facilitating continuity of care, and identifies “high risk” or in need patient populations who would benefit from care coordination.
  • Conducts psychosocial assessment to screen for high-risk patients/families
  • Provides therapeutic/crisis intervention counseling with patients and families as needed.
  • Leads and coordinates the engagement strategy for BH & Wellness Patients
  • Performs patient outreach for new patient referrals to set expectations for the intake and ensure patient video visit enablement
  • Tracks, manages, and engages patients who have fallen out of care 
  • Tracks and manages: utilization, third next available, and other important performance metrics for assigned providers
  • High-risk patient follow-up and tracking
  • Send step up referrals for adults and youth to the County Behavioral Health Department.
  • Manage patient panels and care lifecycle within the department; monitoring and reporting that episodes of care observe internal guidelines (ex: treatment plan documentation, notes communicated to PCP, screeners documented, etc.)
  • Care transition management to and from Family Medicine, OB or other departments
  • Perform chart review on patients physical/medical care and outside referrals to ensure to BH/Wellness provider is updated on plan of care
  • Receives patient requests for assistance and refers patient to appropriate member of the care team for resolution.
  • Works with the patient to coordinate transition of care information, including obtaining authorizations, medical records, consult notes, and making and confirming appointments
  • Practices regular communication with care team members to expand knowledge of available community services available for patient referral
  • Coordinates the development and facilitation of groups such as MAT, Living in Balance, Freedom from Nicotine, Play, Diabetes Management, etc. Remains aware of and develops relationships with community resources and services offered, such as (and not limited to)behavioral health, housing, food, and employment assistance, and provides information on such services to patients and family members as needed. 

Quality Improvement

  • Assists with implementation of department-based performance and quality improvement activities resulting in improved operations and patient outcomes
  • Leads patient screening efforts, including monitoring and facilitating patient screening, ensuring EHR documentation, and tracking and trending reporting
  • Uses clinical knowledge to evaluate the quality and effectiveness of clinical performance, using data collected by internal and external monitoring processes.
  • Uses ongoing strategic and systemic processes to gather data and assess and improve the quality and timeliness of behavioral health services provided
  • Collaborates on grants to support quality improvement and population health initiatives with robust evaluation methodology, grant seeking and grant reporting efforts, as applicable.
  • Ensures effective communication and meaningful reporting of quality improvement activities and outcomes to key internal stakeholders.
  • Monitors preventative care gaps and assists in scheduling patients to complete screenings.
  • Provides education to facilitate attainment of clinical metrics. Develop training materials for provider/support services to promote understanding of clinic metrics and cross-functional responsibilities for interventions/outcomes

Workflow Standardization and Training

  • Creates, maintains, and trains on operational workflows that ensure care coordination and continuity
  • Assist in ensuring that intake forms requirements such as Consent for Treatment, Release of Information, intake questionnaires, or Beacon/county referral forms are completed.

BH Chronic Care Management Enablement

  • Identifies and enrolls eligible CCM patients at health center; ensures provider documents patient consent to participate in CCM program
  • Coordinates with other behavioral health providers to ensure that patient Care Plans are documented and updated at least every six months. 
  • Coordinates with care team (i.e. PCP, Case Management, etc.) to support external community care services for high-risk patients related to their health condition; ensures recommended services were obtained and report out to BH/Wellness providers
  • Meet with CCM patient to monitor progress against documented Care Plan and continue monthly or otherwise established meetings with CCM patients.  Inform on progress to appropriate care team members
  • Establish one’s self as point of contact for patients on CCM panel, who can then triage patient requests to other members of care team as needed
  • Maintain and share dashboard of key process and outcome measures for use in quality assurance and quality improvement of CCM Program
  • Oversee quality assurance and quality improvement of CCM Program, with support from manager

Professional Development and Relationships:

• Utilizes Continuing Education resources to ensure compliance and skills necessary to practice in PHC treatment model. Willingly seeks additional training when needed in order to successfully fulfill job requirements
• Models clear communication and conflict resolution skills with coworkers and patients
• Continually assesses needs of community and patients, and trends in psychology, to ensure cutting-edge treatment
• Participates in quality improvement initiatives. Adheres to quality assurance guidelines and aids the health center in reaching its clinical quality goals. Adheres to nationally recognized health care standards
• Knows and follows clinic policies and procedures
• Demonstrates competent knowledge in delivering behavioral health services to patients through peer review as established through the medical staff bylaws, recommendations of each licensing Board, and clinic Quality improvement Program
• Supports and contributes in a positive manner to clinic efforts to maintain and improve patient
satisfaction in all aspects of care delivery
• Attends and actively participates in supervision for oversight of clinical work. Responsible for
maintaining all records and communication for licensing eligibility and for the acquisition of a license when hours are complete.
• Willingly performs other duties within the scope of practice as assigned

Experience and Skills:


Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

**New employees are mandated to either provide proof of their COVID vaccination or to receive the vaccine, either through PHC or their own provider, with the first dose of a series required before the first day of employment. Exception to this mandate will be considered for those with a medical or religious exemption.

Experience/Specialized skills (including Language)

  • 3+ years of social work or direct patient care experience preferred
  • Case management experience preferred
  • 2+ years of experience in healthcare quality, quality improvement, quality assurance or similar field preferred
  • Bilingual in English and Spanish preferred
  • Strong communication skills with the ability to effectively interact through various mediums and adjusting language and presentation to capture the attention of various audiences.
  • Outstanding critical thinking skills in assessing and resolving a wide range of issues relative to outcomes or alternative approaches.


• Master’s degree in Social Work from an accredited School of Social Work

  Licenses and Certifications:

  • A valid and active Associate Clinical Social Worker (ACSW) registration issued by the California Department of Consumer Affairs, Board of Behavioral Sciences.
  • Active and valid Associate Clinical Social Worker registration must be maintained continuously until

successful completion of the examination process for licensure as a Licensed Clinical Social Worker.

  • Registered Associate Clinical Social Workers must obtain licensure within six (6) years from the

        original date of registration with the California Department of Consumer Affairs, Board of Behavioral

        Sciences. Failure to obtain licensure within the aforementioned timeframes may result in termination.

  • Basic Life Support required.


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Desired Skills:

  • Strong customer service skills
  • Team leadership skills
  • Excellent communication skills
  • Basic working knowledge of insurance coverage, claims submission and pre-authorization process
  • Sensitivity to the needs and situations of multi-cultural populations from a variety of income levels
  • Project management and/or workflow development skills in a clinical setting
  • Familiarity with basic clinical quality improvement and assurance principals and metrics
  • Excellent attention to detail
  • An energetic and creative individual with high standards and an appropriate professional image.
  • Proven ability to handle multiple projects and meet deadlines
  • Versatility, flexibility and willingness to work within an ambiguous, fast-paced environment
  • Demonstrated resourcefulness in providing solutions and setting priorities
  • Effective interpersonal skills to work effectively with all levels within the health center
  • Strong verbal and written communication skills with demonstrated ability to communicate clearly and effectively at all levels
  • Maintains a sense of humor

 Language Skills: Ability to effectively present information and respond to questions and requests from patients, co-workers, and others as necessary. Bilingual in English and Spanish, both written and verbal preferred.

Mathematical Skills: Ability to add, subtract, multiply, divide in all units of measure, using whole numbers, common fractions and decimals.

Reasoning Ability: Ability to recognize problems, collect data and establish facts.

Computer Skills: High level of computer literacy and proficient in MS Office (Word, Excel and Outlook), electronic medical records and web applications. Ability to type 35 WPM.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Movement within health center complex environment repeatedly throughout the day
  • Ability to write by hand, use phone, use computer keyboard and mouse extensively to perform general office functions
  • Manual wrist and finger dexterity and wrist-finger speed sufficient to perform repetitive actions for extended periods of time
  • Ability to effectively communicate by hearing continuously and speech in a manner which can be understood by a diverse population
  • Ability to give and follow verbal and written instructions with attention to detail and accuracy
  • Must have visual acuity near and far (20 inches to 20 feet), depth perception, field of vision, ability to focus on an object, ability to identify and distinguish colors
  • Ability to sit or stand for extended periods of time (minimum periods of one (1) hour at a time)
  • Ability to frequently walk, bend, squat, stoop, kneel, twist, crouch, and climb with the use of a step stool
  • Ability to grasp, hold and pick up and reach with hands and arms
  • Ability to frequently lift and or move up to fifteen (15) pounds
  • Ability to coordinate multiple tasks simultaneously
  • Ability to travel to and from other health center sites and community locations