Behavioral Health Care Manager; Social Worker

Department Overview

Primary Care at Beaverton is located in Beaverton, Oregon. It is a multi-specialty primary care clinic consisting of Internal and Family Medicine Providers who provide healthcare that encompasses the entire life cycle, from birth through pediatric, adult and geriatric patients. Specialty services provided at Beaverton include Sports Medicine.

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 healthcare manager is a core member of the CoCM team, including the patient’s 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 patient’s 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 role will be a limited duration position of 12 months

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 patient’s continuity medical provider and, when appropriate, other mental health providers.

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.

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 so soon to be discharged from the caseload.

Other Duties as Assigned

• A Master’s Social Work (MSW) required.

• Certificate of Clinical Social Work Associate (CSWA) or Licensed Clinical Social Worker (LCSW) required for employees who practice clinical social work.

Job Related Knowledge, Skills, and Abilities (Competencies):

• Ability to utilize assessment information and collateral information to…