POSITION SUMMARY

The Behavioral Health Case Manager (BHCM) is a core member of the collaborative care management (CoCM) team responsible for supporting and coordinating the mental and physical health care of patients on an assigned caseload. Working closely with the patient's medical provider, psychiatric consultant, and the larger primary care team, this position maintains a patient registry, facilitates patient engagement, provides brief behavioral interventions, systematically tracks treatment response, and ensures coordinated care delivery for patients with mental health and substance abuse disorders.

REPORTING RELATIONSHIPS

This position reports to the Director of Behavioral Health Integration. No other positions report to this position.

DUTIES AND ESSENTIAL JOB FUNCTIONS

Patient Care and Caseload Management

• Support the mental and physical health care of patients on an assigned caseload, closely coordinating care with medical providers and other mental health providers as appropriate
• Screen and assess patients for common mental health and substance abuse disorders
• Facilitate patient engagement and follow-up care to ensure continuity of treatment
• Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms, treatment side effects, or complications

Clinical Interventions

• Provide patient education about common mental health and substance abuse disorders and available treatment options
• Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other appropriate treatments
• Support 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 as clinically indicated

Care Coordination and Consultation

• Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant, focusing on patients new to the caseload and those not improving as expected
• Communicate treatment recommendations from psychiatric consultations to the patient's medical provider
• Facilitate treatment plan changes for patients not improving as expected in consultation with the medical provider and psychiatric consultant
• Facilitate referrals for clinically indicated services outside of the organization (e.g., social services, housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment)

Documentation and Registry Management

• Track patient follow-up and clinical outcomes using a registry system
• Document in-person and telephone encounters in the registry and use the system to identify and re-engage patients
• Document patient progress and treatment recommendations in the EHR and other required systems for sharing with medical providers, psychiatric consultant, and other treating providers
• Maintain accurate and timely documentation in accordance with organizational policies and regulatory requirements

Treatment Planning and Discharge

• Develop and complete relapse prevention self-management plans with patients who have achieved their treatment goals and are soon to be discharged from the caseload

REQUIRED QUALIFICATIONS

• Bachelors level degree in a human services field with 2 yrs experience is required
• One of the following licenses/credentials are preferred:
• Licensed Mental Health Counselor/Professional Counselor
• Licensed Marriage and Family Therapist
• Licensed Social Worker (LMSW, LCSW)
• Registered Nurse (BSN recommended) or Nurse Practitioner
• Licensed Psychologist
• Masters-level licensure candidate/trainee with appropriate supervision

Skills and Experience

• Demonstrated ability to collaborate and communicate effectively in a team setting
• Ability to maintain effective and professional relationships with patients and other members of the care team
• Experience with screening for common mental health and/or substance abuse disorders
• Working knowledge of differential diagnosis of common mental health and/or substance abuse disorders
• Ability to effectively engage patients in a therapeutic relationship
• Ability to work with patients by telephone as well as in person
• Experience with assessment and treatment planning for common mental health and/or substance use disorders
• Working knowledge of evidence-based psychosocial treatments and brief behavioral interventions (e.g., motivational interviewing, problem-solving treatment, behavioral activation)
• Basic knowledge of psychopharmacology for common mental health disorders within appropriate scope of practice
• Experience with evidence-based counseling techniques
• Proficiency with electronic health records and registry systems