Collaborative Care Behavioral Health Care Manager

About the role

Yale Health is a multidisciplinary health maintenance organization providing care to Yale’s facility, staff, and students. The Behavioral Health Care Manager (BHCM) supports and coordinates the behavioral and physical health care of patients with a focus on common mental health conditions.

Responsibilities

• Care Management & Care Coordination
• Support the behavioral and physical health care of patients on an assigned caseload
• Closely coordinate care with medical providers, psychiatric consultant, and other care team members
• Collaborate with Internal Medicine and OB/GYN clinicians to develop and implement integrated care plans
• Facilitate referrals to specialty mental health, substance use treatment, and community-based services as clinically indicated
• Screening, Assessment & Engagement
• Screen and assess patients for common mental health and substance use disorders using validated tools
• Conduct clinical assessments, including risk assessment and safety planning as appropriate
• Facilitate patient engagement in treatment and ensure ongoing follow-up care
• Provide patient education on mental health conditions and available treatment options
• Measurement-Based Care & Registry Management
• Systematically track treatment response and monitor patients for changes in symptoms, treatment adherence, and side effects
• Maintain and utilize a patient registry or equivalent system to track clinical outcomes and identify patients requiring outreach
• Proactively follow up with patients who are not improving or who are lost to follow-up
• Brief Interventions & Medication Support
• Provide brief, evidence-based behavioral interventions
• Support psychotropic medication management prescribed by medical providers by monitoring adherence, effectiveness, and side effects
• Reinforce treatment plans and promote patient self-management strategies
• Psychiatric Consultation & Stepped Care
• Participate in regular caseload consultation with the psychiatric consultant
• Present new and complex cases, as well as patients not improving as expected
• Communicate psychiatric treatment recommendations to medical providers and support implementation
• Facilitate treatment plan adjustments using stepped-care principles
• Care Transitions & Relapse Prevention
• Facilitate transitions to higher levels of care when clinically indicated
• Develop relapse prevention and self-management plans for patients achieving treatment goals
• Support planned discharge from the CoCM caseload
• Program Operations & Documentation
• Document patient progress, assessments, and treatment plans in accordance with organizational and CoCM requirements
• Support adherence to Collaborative Care workflows, including population-based care delivery and outcome tracking
• Participate in program development, quality improvement initiatives, and team-based care processes

Requirements

• Master’s degree in social work and at least three years of experience providing clinical care post-independent clinical licensure
• State of CT Licensed Clinical Social Worker or ability to obtain CT LCSW before hire

Qualifications

• Strong clinical assessment and risk management skills
• Ability to manage a population-based caseload using data and registries
• Effective interdisciplinary collaboration
• Strong organizational, communication, and follow-up skills

Skills

• Experience in Collaborative Care Model (CoCM) or integrated behavioral health
• Experience in perinatal mental health or women’s health populations
• Familiarity with measurement-based care and registry tools
• Experience delivering brief, structured, evidence-based interventions

Benefits

N/A

Pay

$82,000.00 - $131,500.00

Schedule

Full-time; 37.5 HRS; Weekdays, Flexible Schedule. Generally Monday – Friday, between 8:30 a.m. – 5:00 p.m.; may be required to work evenings, weekends or holidays. May participate in on-call rotation.