Behavioral Health Case Manager; San Ysidro, CA

Job Description

Posted Friday, January 23, 2026 at 11:00 AM

Under the supervision of the Program Manager, the Behavioral Health Case Manager is responsible for providing direct services and coordinating care for behavioral health patients with particular focus on those with complex needs. 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 develops an evidence‑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.

• Provides direct services to patients, including case management, rehabilitative services, warm handoffs, and/or psycho‑educational groups.
• Conducts comprehensive assessment of the patients’ health and psychosocial needs, including health literacy status and deficits, and develops case management plan in 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 been scheduled with Behavioral Health, ensuring patients have access using in person and telehealth appointments.
• Represents San Ysidro Health and Behavioral Health Department to other organizations to create and maintain partnerships with other community programs to improve referral outcomes and quality of care toward patients.
• Conducts GPRA assessments as part of CCBHC program.
• Maintains timely, complete, and accurate records with detailed assessment results, action plan, and progress notes, documenting plans discussed with the patient, family, Behavioral Health Clinicians, PCPs, etc. in the electronic health record system to ensure 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.

• Begin developing the therapeutic alliance with patients by providing orientation to mental health services.
• Uses IMPACT / ESBIRT model for treatment; coordinates patient care with Behavioral Health provider, Primary Care Physician, and psychiatrist via consultation, collaboration, follow up, and recommendations.
• Ensures that patients obtain necessary referrals to needed services as established in case plans including but are not limited to medication assistance, housing, mental health…