Collaborative Care Behavioral Health Care Manager

Behavioral Health Care Manager

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In 1971, Yale University established Yale Health to provide health services to its facility, staff and students through a multidisciplinary health maintenance organization located on campus. Yale Health has more than 50,000 members including students, staff, faculty and their families who come from every state in the country and almost every country in the world. With over 50 years of service to the Yale community, our state-of-the-art facility at 55 Lock Street, is where our members receive most of their care from our 150+ providers. It is a 144,000 square foot medical facility with over 90 exam rooms, an Acute Care Department, a 15-bed inpatient facility with two negative pressure rooms, a diagnostic imaging suite including MR and CT scan, x-ray and ultrasound and a full-service retail pharmacy.

The Behavioral Health Care Manager (BHCM) is a core member of the Collaborative Care Model (CoCM) team, working in partnership with the patient's medical provider (Internal Medicine or OB/GYN) and a psychiatric consultant, as well as the broader care team. The BHCM is responsible for supporting and coordinating the behavioral and physical health care of patients on an assigned caseload, with a focus on common mental health conditions including depression, anxiety, and perinatal mood and anxiety disorders. This role delivers measurement-based, population-focused care, including patient engagement, brief evidence-based interventions, systematic outcome tracking, and proactive care coordination to improve clinical outcomes and access.

Responsibilities include:

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 (e.g., social services, perinatal supports).

Screening, Assessment & Engagement

Screen and assess patients for common mental health and substance use disorders using validated tools (e.g., PHQ-9, GAD-7, EPDS). 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 (in person and/or via telephone/virtual care) 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. Document all patient encounters and clinical data in the electronic health record and registry systems.

Brief Interventions & Medication Support

Provide brief, evidence-based behavioral interventions (e.g., behavioral activation, problem-solving treatment, motivational interviewing). 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 (typically weekly) 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. Perform additional responsibilities as assigned.

Schedule/Shift: 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.

Required Skills and Abilities

1. Strong clinical assessment and risk management skills.

2. Ability to manage a population-based caseload using data and registries.

3. Effective interdisciplinary collaboration.

4. Patient-centered, culturally responsive care Strong organizational, communication, and follow-up skills

Preferred Skills and Abilities

3 - 5 years Clinical behavioral health experience; experience in integrated care, primary care, or women's/perinatal health. Experience in Collaborative Care Model (CoCM) or integrated behavioral health; perinatal mental health or women's health populations; familiarity with measurement-based care and registry tools and delivering brief, structured, evidence-based interventions.

Principal Responsibilities

1. Provides clinical care management for individuals requiring assistance, support, and follow-up contact. Monitors care access wait times to ensure timely access to services.

2. Interacts with contacts such as patients, families, clinicians, medical staff, and administrators regarding the treatment of individual patients and the implementation of clinical programs.

3. Serves as the primary referral coordinator for mental health care to help ensure patients have access to the appropriate level of care.

4. Monitors mental health screening outcomes to support appropriate referrals when needed.

5. The clinician may provide brief clinical assessments, evaluations, and interventions while patients are connecting with providers.

6. Coordinates with contracted behavioral health provider network to resolve patient issues, track care metrics, and identify trends.

7. Track referrals and provide appropriate follow-up assistance as needed.

8. Develop and maintain a local, national, and international mental health resources database.

9. Authorizes referrals and communicates with internal and external business partners as needed to ensure coverage of appropriate services.

10. Functions as the primary contact for patients about mental health services.

11. May coordinate with external mental health facilities and/or providers to identify and facilitate higher-level care options, support aftercare planning needs, and ensure continuity of care across the continuum of mental health services.

12. Establishes and maintains strong working relationships with department leadership, clinicians, patients, and university stakeholders.

13. Adheres to the expectations of strict health information privacy and confidentiality.

14. Provide educational and consultation services as needed. May develop materials for educational programs and seminars for professional staff.

15. May perform other duties as assigned.

Required Education and Experience

Master's degree in social work and at least three years of experience providing clinical care post-independent clinical licensure.

Required License(s) or Certification(s)

State of CT Licensed Clinical Social Worker or ability to obtain CT LCSW before hire.