BEHAVIORAL HEALTH CARE MANAGER JOB DESCRIPTION

Collaborative care teams in primary care and managed care settings depend on a licensed clinician who can carry a caseload of patients with depression, anxiety, serious mental illness, and substance use disorders, without offloading every complex case to specialty psychiatry. That clinician is the Behavioral Health Care Manager. Working under frameworks like the CMS-recognized Collaborative Care Model, this role owns the registry: tracking treatment response, adjusting care plans, and consulting the psychiatric supervisor when a patient plateaus. Caseload size and NCQA transition-of-care benchmarks define the operational tempo here, not referral volume.

As the Behavioral Health Care Manager, you coordinate the behavioral health care of an assigned patient population within an integrated primary care or managed care setting, ensuring evidence-based treatment plans are implemented, monitored, and revised until measurable clinical improvement is documented. You operate as a peer member of a multidisciplinary team, alongside primary care providers, a psychiatric consultant, and community health partners, with accountability for population health metrics across your caseload.

Career Impact: Mastery of the Collaborative Care Model and structured caseload management positions experienced clinicians for lead behavioral health or clinical program director roles within integrated health systems.

Business Impact: Patients under active behavioral health care management show measurably lower rates of avoidable psychiatric hospitalization and emergency department use - outcomes that determine whether integrated programs retain Medicaid and Medicare contracts.

Growth Opportunity: Exposure to Medicaid/Medicare regulatory compliance, NCQA quality reporting, and population health data management builds a skill set that transfers directly into health plan clinical operations and value-based care leadership.

• Manage an assigned behavioral health caseload using a population health registry to track treatment response, clinical outcomes, and follow-up completion.
• Screen and assess patients for common mental health and substance use disorders using validated tools, and develop individualized, person-centered care plans in collaboration with the primary care provider and psychiatric consultant.
• Provide brief behavioral interventions using evidence-based techniques including behavioral activation, problem-solving treatment, and motivational interviewing, calibrated to the primary care setting.
• Monitor patients in person and by telephone for changes in clinical symptoms, treatment side effects, and adherence to the plan of care across care settings.
• Coordinate referrals to clinically indicated services within and outside the organization, including mental health specialty care, substance use disorder treatment, housing assistance, and community social services.
• Facilitate transitions of care for members discharging from inpatient psychiatric stays, ensuring 7-day and 30-day follow-up benchmarks are met and discharge plans are documented and executed.
• Consult regularly with the psychiatric supervisor during scheduled caseload review meetings and communicate resulting treatment recommendations to the patient's primary care provider.
• Document all clinical encounters, care plan updates, and coordination activities in the electronic health record in compliance with HIPAA and program documentation standards.

• Bachelor's degree in Social Work, Counseling, Psychology, or a related behavioral health field, or equivalent work experience.
• 3 or more years of clinical experience in behavioral health care management, medical social work, or outpatient counseling, with exposure to complex psychiatric and substance use disorder presentations.
• Current, active licensure in good standing as an LCSW, LICSW, LMHC, LPC, LMFT, or equivalent clinical license as permitted by applicable state law.
• Working knowledge of evidence-based brief interventions including motivational interviewing, behavioral activation, and problem-solving treatment.
• Demonstrated experience conducting mental health and substance use disorder screenings using validated assessment instruments.
• Experience documenting clinical encounters in an electronic health record system and maintaining compliance with HIPAA and confidentiality requirements.
• Strong organizational skills with the ability to manage a high-volume caseload, prioritize competing urgencies, and operate with minimal supervision.
• Ability to collaborate effectively within an interdisciplinary care team including primary care providers, psychiatrists, social workers, and community health partners.

• Master's degree (MSW, MS, or MA) in Social Work, Counseling, or Clinical Psychology from an accredited program.
• Experience with Medicaid, Medicare, FIDA, HARP, or other managed care product lines, including knowledge of regulatory reporting and utilization management processes.
• Proficiency in managing population health registries or care facilitation platforms, including familiarity with NCQA transition-of-care standards.
• Bilingual fluency in Spanish or another language prevalent in the communities served.

• Caseload follow-up rate at 7 and 30 days post-discharge, measuring adherence to NCQA transition-of-care benchmarks.
• PHQ-9 and GAD-7 score trajectory across the caseload, reflecting treatment response among patients with depression and anxiety.
• Registry completion rate, tracking the percentage of active patients with a documented, current care plan.
• Avoidable psychiatric emergency department visits per 1,000 caseload members per quarter, attributable to active care management intervention.
• Referral completion rate, measuring how often facilitated community and specialty referrals result in a documented first appointment.
• Typical tools: Electronic health records (commonly Athena, Epic); population health registry platforms; telehealth and secure messaging platforms.

• Base Salary Range: $60,000-$85,000 annually, depending on licensure level and setting
• Bonus: Annual performance bonus of 3-7%, tied to caseload and quality metrics
• Equity: Not typical in most healthcare and managed care settings
• Health Benefits: Medical, dental, and vision coverage; employer contribution standard
• PTO: 15-22 days annually, plus federal holidays
• Common Perks: Licensure supervision support, CEU reimbursement, mileage or telehealth stipend

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Employment is contingent on successful completion of a background check and, where applicable, verification of licensure in good standing. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, or any other characteristic protected under applicable federal, state, and local law. Reasonable accommodations for qualified individuals with disabilities are available upon request. Candidates must be authorized to work in the United States.

The Behavioral Health Care Manager delivers coordinated mental health care as a core member of the collaborative care team, partnering with longitudinal medical providers and psychiatric consultants to develop and adjust individualized treatment plans. Reporting to the care team structure, this work supports adult patients through psychotherapy, medication management, and systematic progress tracking to achieve key population health metrics.

Key Responsibilities

• Act as the primary contact person for each patient in their mental health treatment journey.
• Consult regularly with longitudinal care providers and psychiatric consultants to develop and adjust each patient's treatment plan.
• Deliver psychotherapy, support medication management, and alert the team when a patient's condition is not improving.
• Perform regular mental health screenings and track each patient's progress to ensure key population health metrics are achieved.
• Systematically track treatment response and monitor patients in person or virtually for changes in clinical symptoms and treatment side effects or complications.

Required Qualifications

• Active New York license as an LCSW, LPC, LMHC, or clinical psychologist with at least 5 years of clinical experience.
• 10 or more years of clinical experience preferred.
• Experience working within the collaborative care model.
• Tech-savvy with experience using Google Suite and treating patients virtually.
• Strong organizational and communication skills.
• Fluency in Spanish and multilingual ability.
• Ability to commute regularly to the assigned clinic.

Embedded within TrueCare's care coordination team, the Behavioral Health Case Manager I builds patient capacity to direct their own health care experience through supportive and psycho-educational interventions, linkage to community resources, and coordination across the continuum of care. Working closely with providers, external organizations, and community partners, this role strengthens coping stability through individualized care planning and documented referral follow-up.

Core Functions

• Promote and reinforce Patient Centered Medical Home concepts with patients and staff.
• Identify patient and family physical, psychosocial, environmental, safety, and developmental needs, and assist the healthcare team in developing individualized care plans.
• Assist patients in problem-solving issues related to the health care system, financial barriers, or social barriers, including completion of disability paperwork.
• Serve as a resource contact and information source to patients, families, providers, and staff.
• Coordinate referrals for continuity of care with external organizations and community resources, and follow up to document use and success of referrals.
• Collaborate with providers and staff to ensure delivery of quality care and best patient outcomes.
• Maintain up-to-date patient records and document problems, goals, interventions, and outcomes accurately.
• Participate in program development, orientation, and educational activities to further patients' capacity to direct their health care experience.
• Maintain thorough knowledge of TrueCare services, community resources, and applicable federal and state laws affecting health care planning.
• Attend program-related community, coalition, and committee meetings as assigned.

Qualifications & Experience

• High school diploma or equivalent, with an Associate's degree in social services, mental health, psychology, or a related field preferred.
• Medical Assistant Certificate preferred.
• 1 to 2 years of experience in a clinical setting.
• Experience in brief interventions and case management techniques.
• Knowledge of local and national health care resources and basic working knowledge of subject matter.
• Computer proficiency in Microsoft Office Suite products, including Outlook, Word, Excel, and PowerPoint, and in electronic health record systems.
• Bilingual fluency in English and Spanish.

Reporting to the behavioral health leadership team, the Behavioral Health Case Manager II leads complex case management for members requiring hospital discharge support, conducting individualized assessments and developing targeted care plans that address clinical and social determinants of health. Partnering with internal and external resources, providers, and Utilization Management, this role supports appropriate, cost-effective care and serves as a resource to fellow BH Case Managers.

Primary Duties

• Respond to complex cases including members requiring hospital discharge support and account-specific requests.
• Use screening criteria and clinical judgment to assess member needs and conduct individualized assessments.
• Develop specific care plans to address objectives and goals, with discharge planning prioritizing medication, transportation, and post-discharge appointment needs.
• Monitor and evaluate the effectiveness of care plans, modify plans as needed, and identify clinical and social determinants of health that drive hospitalizations and ED utilization.
• Support member access to appropriate, quality, cost-effective care.
• Coordinate with internal and external resources to meet member needs, collaborate with providers, and consult with Utilization Management as appropriate.
• Serve as a resource to other BH Case Managers and participate in cross-functional team projects and initiatives.

Skills & Qualifications

• MA or MS in social work, counseling, a related behavioral health field, or nursing, or an equivalent combination of education and experience.
• Current, active, unrestricted license such as RN, LCSW, LPC, or LMFT as applicable by state law.
• Minimum of 3 years of clinical experience in social work or counseling with complex psychiatric and substance use disorder cases.
• Previous experience in case management and telephonic or in-person coaching with members with complex psychiatric, substance abuse, or medical disorders.
• Managed care experience.
• Experience in health coaching and motivational interviewing techniques preferred.

Sitting at the intersection of crisis intervention and clinical access services, the Behavioral Health Care Manager delivers timely intensity-of-service determinations and crisis screening for callers across a range of acuity levels, ensuring appropriate linkage to community resources. Operating across telephonic and direct service channels under approved clinical criteria, this role upholds customer service agreements and recognized ethical standards while supporting the broader behavioral health care team.

Duties

• Make timely intensity-of-services determinations or refer to higher-level review when indicated.
• Provide linkage to community services as needed and identify a wide range of community resources for callers.
• Adhere to customer service level agreements, expected productivity measures, documentation requirements, and recognized ethical standards.
• Screen and assess crisis or emergency calls and evaluate caller acuity, severity, and clinical necessity for treatment based on approved criteria.
• Demonstrate respectful communication and excellent customer service in all interactions.
• Complete all required trainings on time and assist with projects as assigned.

Requirements

• Master's degree from an accredited program in Social Work, Clinical or Counseling Psychology, or Nursing.
• Active NJ clinical licensure as an Advanced Practice Nurse in mental health or youth services, LCSW, LMFT, LPC, Licensed Psychologist, or Licensed Psychiatrist.
• Minimum of 2 years of experience in children's mental health, DCPP, juvenile justice, or a related public sector human services or behavioral healthcare field providing community-based services.
• Background in family systems, community systems and resources, case management, child and family counseling, child protection, or child development.
• Clinical and cultural competency to manage complex cases across child-serving systems.
• Demonstrated knowledge of varied approaches to intervention and support.
• Computer savvy.
• Proven ability to multi-task.

A key member of Bluestone's collaborative care team, the Behavioral Health Care Manager leads evidence-based behavioral interventions and care planning for patients with Alzheimer's and related dementias across multiple service areas. Collaborating with primary care providers, psychiatric consultants, and community caregivers, this role supports patients and families in reducing behavioral episodes and maintaining quality of life.

Functions

• Provide ongoing education and support to patient care teams on Alzheimer's disease, related dementias, and Serious and Persistent Mental Illness diagnoses and their impact on cognitive function.
• Establish care plans that outline interventions to reduce behavioral episodes and improve function and safety.
• Provide behavioral interventions using evidence-based techniques such as motivational interviewing, problem-solving, modeling, and active listening.
• Identify and provide de-escalation strategies and crisis resources for caregivers, patients, and families.
• Provide non-pharmacological behavior prevention and reduction solutions and develop strategies to anticipate and calmly de-escalate distress behaviors.
• Systematically track treatment response and complete validated rating scales monthly to monitor response to care plan interventions.
• Participate in regularly scheduled caseload consultations with internal and external psychiatric consultants.
• Facilitate referrals for clinically indicated services outside the organization and build community staff skills through education and relationship building.

Experience & Qualifications

• Formal education or specialized training in behavioral health, including social work, nursing, psychology, or a related field.
• 1 or more years of experience in memory care or dementia-related care.
• Knowledge of behavioral health, dementia, care planning, assessments, and screenings for mental health disorders.
• Intermediate-level computer proficiency, including email, word processing, spreadsheets, and databases.
• Ability to communicate effectively and professionally with diverse populations and maintain professional relationships with patients and care team members.
• Strong time-management, organizational, and customer service skills with ability to work independently.
• Valid driver's license.

Optimal health outcomes for adult and adolescent patients with complex behavioral health needs depend on the Behavioral Health Care Manager, who shapes individualized care plans by integrating evidence-based clinical guidelines with comprehensive assessment across the primary care setting. Based within a multidisciplinary care management team alongside a psychiatric consultant, this role monitors high-risk patients, manages care transitions, and ensures cost-effective, quality-driven service delivery under minimal supervision.

Accountabilities

• Manage patient cases and provide targeted interventions to avoid hospitalization and emergency room visits.
• Help patients and families understand health care options and provide self-management support.
• Assess patient health, emotional status, and psychosocial needs using standard assessment tools.
• Collaborate with the primary care provider, psychiatrist, and care team to develop comprehensive individualized care plans.
• Implement systems to facilitate close monitoring of high-risk patients and provide timely follow-up during care transitions.
• Provide daily oversight of hospital and skilled nursing facility admission and discharge feeds.
• Respond to telephonic inquiries from patients, practices, and payers.
• Counsel and educate clinical staff on billing compliance and ensure program compliance with HIPAA and related information security policies.

Position Requirements

• Current Michigan RN license (BSN preferred), Master of Social Work license, Licensed Mental Health or Professional Counselor license, or Licensed Psychologist license.
• 3 years of experience with adult and pediatric patients in primary care, ambulatory care, home health, skilled nursing, or hospital settings within the past 5 years.
• Specialized training or experience in behavioral health within the past 5 years.
• Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, risk assessment, patient education, and CPT billing codes.
• Proficiency in Microsoft Office and email communication.
• Knowledge of multiple electronic medical records applications.
• Excellent written and oral communication skills and ability to work in a multicultural setting.
• Valid driver's license and access to reliable transportation.

As the Behavioral Health Care Manager, this role delivers coordinated psychiatric and primary care services for WVU students, screening for mental health and substance use disorders and facilitating brief evidence-based interventions through the Carruth Center for Psychological and Psychiatric Services. The collaborative care team relies on this work to connect students with services across WVU Medicine, the broader university, and the Morgantown community.

Activities

• Support the mental and physical health care of students on an assigned caseload and closely coordinate care with the student's medical provider and other mental health providers as appropriate.
• Screen and assess students for common mental health and substance use disorders, and facilitate patient engagement and follow-up care.
• Provide student education about common mental health and substance use disorders and available treatment options.
• Systematically track treatment response and monitor patients for changes in clinical symptoms, treatment side effects, and complications.
• Support psychotropic medication management as prescribed by medical providers, focusing on treatment adherence, side effects, and effectiveness.
• Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, and motivational interviewing.
• Provide risk assessment and reduction interventions for students presenting in crisis or with acute distress.
• Facilitate referrals for clinically indicated services within and outside of WVU, including community resources such as Accessibility Services and Collegiate Recovery.
• Participate in scheduled caseload consultations with the psychiatric consultant and communicate treatment recommendations to the student's medical provider.
• Develop and complete relapse prevention self-management plans with students who have achieved their treatment goals.

Knowledge Skills & Abilities

• Master's degree in Counseling, Psychology, or Social Work (MA, MS, or MSW).
• License or license-eligibility as a Counselor, Social Worker (LICSW), or Psychologist within 18 months in the State of WV.
• 5 years of experience providing case management or short-term individual counseling with adults, including intake and triage assessment and crisis stabilization in outpatient or hospital settings.
• Experience screening for common mental health and substance use disorders and working knowledge of differential diagnosis.
• Proficiency in Electronic Health Record use.
• Experience with data management software.
• Demonstrated commitment to cultural humility and affirmative care for all students.

Behavioral Health Care Manager leads psychosocial assessment, care plan development, and face-to-face and telephonic intervention for complex members with serious mental illness, substance use, and social care needs within the PP Multidisciplinary Team. The work directly supports optimal wellness outcomes by integrating solution-focused treatment, motivational interviewing, and cross-system coordination with primary care physicians, behavioral health providers, inpatient services, and community partners.

Operational Focus

• Assess member psychosocial needs and collaborate with team members and health care providers to develop a plan of care supporting optimal wellness within the context of mental illness, medical condition, and entitled benefits.
• Utilize solution-focused treatment, behavior modification, and motivational interviewing to improve member clinical outcomes and self-management skills.
• Support members and caregivers through telephonic and face-to-face interventions, and collaborate with primary care physicians and specialists to manage medical and behavioral health symptoms.
• Collaborate with team members to develop individualized discharge and home care plans for high-risk or complex members using cost-effective interventions.
• Serve as an advocate for the member during and following an inpatient psychiatric stay to ensure proper utilization of services and a safe discharge plan.
• Facilitate communication with behavioral health providers, inpatient and outpatient services, PCP offices, community partners, and state agencies.
• Communicate and consult with clinical teams regarding social determinants of health and their impact on member health status and outcomes.

Professional Experience

• Master's degree in Social Work or Mental Health Counseling.
• Current Massachusetts licensure in good standing as a LADC, LCSW, LICSW, or LMHC preferred.
• 3 to 5 years of experience in behavioral health care management, medical social work, serious mental illness, or substance use treatment.
• Experience with evidence-based behavioral health treatment, motivational interviewing, and health coaching.
• Experience working with pediatric populations, adolescents, families, serious mental illness, and substance use.
• Cultural competency, sensitivity, initiative, and ability to work autonomously and adapt to changing priorities.
• Strict regard for confidential data and adherence to corporate compliance policy.

The Behavioral Health Care Manager owns care management and coordination across Medicaid and Medicare product lines, including FIDA, CompleteCare, SNP, and HARP, addressing the needs of frail adult and cognitively impaired senior populations. Assigned to a specific product line and partnering with a multidisciplinary health care team, this role generates referrals, coordinates care plan goals, and maximizes member outcomes across downstate New York.

Key Deliverables

• Advocate, inform, and educate beneficiaries on services, self-management techniques, and health benefits.
• Conduct assessments to identify barriers and opportunities for intervention, and develop care plans aligned with the physician's treatment plan.
• Generate referrals to providers, community-based resources, and appropriate services to assist members in achieving care goals.
• Collaborate with provider doctors, social workers, discharge planners, and community-based service providers to coordinate care.
• Coordinate with the multidisciplinary health care team to ensure care plan goals are achieved, and member outcomes are maximized.
• Identify opportunities for alternative care options based on member needs and assessments, and evaluate service authorizations for alignment with the member's care and physician treatment plan.
• Document all encounters with providers, members, and vendors in the appropriate system per established documentation procedures, and update care plans based on member needs as appropriate.

Background & Experience

• Current NYS RN, LCSW, LMSW, LMFT, LMHC, LPC, or licensed psychologist license (any state).
• Relevant work experience preferably as a Care Manager.
• Knowledge of the relevant product line and community health practices for frail adult and cognitively impaired senior populations.
• Knowledge of InterQual and LOCADTR.
• Proficiency in Microsoft Excel and multiple electronic documentation systems.
• Experience managing member information in a shared network environment using paperless database modules.
• Strong interpersonal and assessment skills with the ability to handle rapidly changing crises and manage large caseloads effectively.
• Fluency in Spanish, Korean, Mandarin, or Cantonese preferred.

Embedded within Cityblock's integrated care team, the Behavioral Health Care Manager shapes population health outcomes for members with significant behavioral health and substance use disorder needs, managing transitions of care, triaging referrals, and developing shared action plans using motivational approaches. Working closely with primary care providers, community health partners, psychiatrists, and BH Therapists, this role ensures members achieve designated health outcomes and utilize internal and external resources effectively.

Areas of Ownership

• Manage a designated population of members with significant behavioral health and substance use disorder needs as a population health care manager.
• Be accountable for BH quality metrics for assigned populations.
• Refer to Cityblock Behavioral Health Specialists and facilitate referrals to external community therapists, psychiatrists, and other behavioral health resources as needed.
• Follow up closely with members to ensure they follow through with care recommendations and eliminate barriers to engagement with internal and external providers.
• Assess member readiness to change, anticipate relapse from substance use disorders, and intervene accordingly.
• Follow members closely during inpatient stays, detox or withdrawal management programs, residential programs, and intensive day programs, and liaise with inpatient and care teams to ensure continuity of care.
• Ensure transitions of care follow-up and escalation plans are detailed and achievable, with follow-up appointments scheduled and completed by 7-day and 30-day benchmarks.
• Actively participate in daily team huddles and case conferences to develop and document behavioral health and care management needs and goals as part of each member's Member Action Plan.

Minimum Qualifications

• LICSW, LCSW, or LMHC license with at least 5 years of experience in assessing, planning, and managing patient care, including direct therapy and care management work.
• 3 to 5 years of experience in a care management role in a health plan, ambulatory care, or community service provider managing high-risk populations and transitions of care.
• Working knowledge of Medicare and Medicaid programs.
• Experience with regulatory compliance and reporting requirements.
• Extensive knowledge of Medicare and Medicaid benefits, community resources, and population health registry management.
• Tech-savvy with proficiency in Google Suite, Slack, Google Sheets, and other technology platforms, including ability to document in the moment.
• Advanced communication, interpersonal, and organizational skills.
• Proven ability to develop and sustain relationships with healthcare professionals and community service providers.
• Fluency in Spanish, Vietnamese, French Creole, Cantonese, Russian, or Mandarin preferred.