Behavioral Health Care Manager - LSW, LMHC, LMFT, LMSW

Key Responsibilities Integrated Behavioral Health & Care Coordination Collaborate closely with primary care providers and the integrated behavioral health team to identify, engage, and support patients with behavioral health needs. Referral Management & Community Collaboration Facilitate timely referrals to internal behavioral health clinicians, psychiatric providers, specialty services, and external community resources.

Key Responsibilities Integrated Behavioral Health & Care Coordination Collaborate closely with primary care providers and the integrated behavioral health team to identify, engage, and support patients with behavioral health needs. Facilitate warm handoffs and timely follow-up for patients referred by primary care providers or other members of the healthcare team. Coordinate behavioral health services within the primary care setting, promoting seamless communication and continuity of care. Participate in interdisciplinary care team meetings, case reviews, and treatment planning discussions. Assist patients in navigating behavioral health services, specialty referrals, and community-based resources. Coordinate transitions between levels of care, including outpatient behavioral health services, specialty mental health treatment, and community support programs. Patient Assessment, Engagement & Support Conduct initial behavioral health assessments and screenings within the scope of professional qualifications and organizational protocols. Utilize standardized screening tools, including the PHQ-9 and GAD-7, to assess and monitor symptoms of depression and anxiety. Develop individualized, patient-centered care plans in collaboration with patients and their healthcare team. Maintain ongoing contact with assigned patients to monitor symptoms, treatment adherence, progress, and barriers to care. Provide brief, evidence-informed supportive interventions, patient education, motivational interviewing, and behavioral activation strategies as appropriate to training and scope of practice. Encourage patient participation in treatment decisions, goal setting, and self-management activities. Identify patients who may require additional behavioral health interventions or higher levels of care and facilitate appropriate referrals. Measurement-Based Care & Population Health Management Maintain an active caseload of patients receiving behavioral health care management services. Routinely administer and track standardized behavioral health assessments, including PHQ-9 and GAD-7, according to established clinical protocols. Monitor patient progress and identify individuals who are not demonstrating expected improvement. Communicate clinical concerns and changes in patient status to the appropriate provider or behavioral health clinician. Utilize patient registries, electronic health records, and tracking systems to monitor caseloads, follow-up needs, and treatment outcomes. Support population health initiatives focused on improving behavioral health access, engagement, and clinical outcomes. Assist in identifying patients who may benefit from additional intervention, specialty services, or transition out of active care management. Referral Management & Community Collaboration Facilitate timely referrals to internal behavioral health clinicians, psychiatric providers, specialty services, and external community resources. Follow up on referrals to promote successful connection to recommended services. Assist patients in addressing barriers to care, including transportation, financial challenges, insurance coverage, and other social determinants of health. Establish and maintain collaborative relationships with community mental health agencies and social service organizations. Support patients during transitions of care, including follow-up after behavioral health-related emergency department visits or hospitalizations. Documentation, Quality & Compliance Maintain accurate, timely, and complete documentation of patient interactions, assessments, care plans, and follow-up activities in the electronic health record. Ensure appropriate communication of patient progress, clinical concerns, and care coordination activities to the interdisciplinary team. Follow organizational policies, clinical protocols, and applicable state and federal regulations, including HIPAA and confidentiality requirements. Participate in quality improvement initiatives designed to enhance behavioral health access, patient engagement, and clinical outcomes. Support compliance with FQHC, HRSA, and other applicable program requirements. Complete required organizational training, competency assessments, and continuing education.