Behavioral Health Care Manager (Social Worker)

The behavioral health care manager (BHCM) position is a behavioral health provider who operates in the Collaborative Care Model (CoCM) as part of our integrated behavioral health teams. The behavioral health care manager is a core member of the CoCM team including the patients medical provider (primary care provider or referring specialty provider) and psychiatric consultant traditional health care worker (THW) if available as well as the larger clinic team to ensure continuity of care.

The BHCM is responsible for supporting and coordinating the mental and physical health care of CoCM patients on an assigned patient caseload with the patients primary care provider and the CoCM psychiatric consultant. When appropriate the BHCM may also coordinate care with other internal and external mental health providers.

This position involves a high degree of clinical complexity and advanced level of skill in delivering evidence-based interventions targeted to improve wellbeing and health for a large variety of patients with emotional and behavioral concerns commonly seen in a primary care setting. The work includes screening and assessing patients for common mental health and substance use disorders providing education about these conditions discussing available treatment options and facilitating patient engagement and follow-up care. The BHCM also is responsible for systematically tracking treatment engagement and response (via a registry) and for monitoring patients (either in person by phone or virtual visit) for changes in clinical status and treatment side effects or complications. The BHCM supports the patient in their management of their psychotropic medication focusing on treatment adherence monitoring side effects and effectiveness of treatment. Additionally the BHCM provides brief behavioral interventions using evidence-based techniques such as behavioral activation problem-solving therapy motivational interviewing and other treatments as appropriate. The role also involves participation in regular (weekly) caseload consultation with the psychiatric consultant and communication of resulting treatment recommendations to the patients continuity medical provider.

The BHCM performs duties with minimal supervision. Work is reviewed for adherence to procedures regulations standards and for overall effectiveness. The BHCM position is expected to serve as an advocate for collaborative behavioral health within the physical health care setting.

Counseling:

• Provide brief behavioral interventions using evidence-based techniques such as behavioral activation problem-solving treatment motivational interviewing or other treatments as appropriate.
• Support the patient in their psychotropic medication management as prescribed by medical providers focusing on treatment adherence monitoring side effects and effectiveness of treatment.
• Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments (e.g. problem-solving treatment or behavioral activation) as clinically indicated.
• Support the mental and associated physical health care needs of patients on an assigned patient caseload. Closely coordinate care with the patients continuity medical provider and when appropriate other mental health providers.

Documentation:

• Document patient progress and treatment recommendations in the electronic health record (EHR) and other required systems to be shared with medical providers psychiatric consultant and other treating providers.
• Track patient follow up and clinical outcomes using a registry. Document in-person and telehealth encounters in the registry and use the system to identify and re-engage patients.
• Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.

Psychosocial Assessment:

• Screening and assessment of patients for common mental health and substance use disorders. Facilitate patient engagement and follow-up care.
• Provide patient education about common mental health and substance abuse disorders and the available treatment options.

Patient Services

• Systematically track treatment response and monitor patients (in person or by telephone or virtual visit) for changes in clinical symptoms and treatment side effects or complications.
• Manage collaborative care registry.
• Facilitate referrals for clinically indicated services outside of the organization (e.g. social services such as housing assistance vocational rehabilitation mental health specialty care substance abuse treatment).
• Facilitate treatment plan changes for patients who are not improving as expected in consultation with the medical provider and the psychiatric consultant and who may need more intensive or more specialized mental health care.
• Systematically track treatment response and monitor patients (in person or by telephone or virtual visit) for changes in clinical symptoms and treatment side effects or complications.

• Licensed Clinical Social Worker (LCSW)

Job Related Knowledge Skills and Abilities (Competencies):

• Ability to utilize assessment information and collateral information to conceptualize patient psychopathology.
• Skill and expertise in conducting group and individual psycho-educational classes and brief short-term therapy strategies that will help strengthen the patients overall physical and mental health.
• Incorporation of self-management home-based practice in care planning.
• Skill in efficiently organizing time so that unscheduled same day services are routinely available to care team members.
• The ability to exercise sound judgment in appraising situations and making decisions regarding complex physical and behavioral health treatment issues in consultation with the primary care teams.
• Skill in developing effective working relationships with peers supervisors and professionals in related disciplines.
• Ability to manage complex personal interactions.
• Demonstrated ability to act with minimal supervision on personal initiative using sound clinical judgment.
• Strong written and verbal communication skills.
• Ability to maintain confidentiality regarding patient care information and chart contents as use of patient record and privacy of individuals must be protected to the fullest.
• Ability to maintain documentation in compliance with State Federal Professional and Ethical guidelines

• Training in Primary Care Behavioral Health
• Health care experience
• Experience in behavioral health counseling and brief short-term therapy strategies and case management in an ambulatory setting.
• Experience and/or interest in Collaborative Care.
• Experience in a Primary Care Ambulatory Clinic setting.
• Experience with program development and evaluation.

Job Related Knowledge Skills and Abilities:

• Knowledge of the principles and practices of behavioral health consultation including assessment diagnosis treatment planning cognitive-behavioral counseling strategies and their application to population-based care for preventive and chronic care issues.
• Working knowledge of evidence-based psychosocial treatments and brief behavioral interventions for common mental health disorders when appropriate (e.g. motivational interviewing problem-solving treatment behavioral activation).
• Comprehensive understanding of the interrelationship between medical and psychological systems and their impact on health.
• Experience in documenting clinical activities in a comprehensive clear concise fashion on a same day basis.
• Basic knowledge of psychopharmacology for common mental health disorders

Hours: Variable. Five 8-hour shifts Monday-Friday with possibility of evening or weekend hours. Flexing start/end times to accommodate clinical needs may provided as well.

The work is performed in a medical setting and involves normal working hours with occasional alternative hours for special programs or outreach. The position involves interactions with people who have a wide variety of physical and behavioral health problems. Some travel may be required.

Posted 6/6/2025 2:03pm