Behavioral Health Care Manager

Job Description

Job Description

Position Objective

The Behavioral Health Care Manager delivers comprehensive, coordinated behavioral health care management for select LPO practice units. This position serves as an active, embedded member of the primary care team — working alongside primary care providers and a consulting psychiatrist to identify, engage, treat, and track a caseload of patients with behavioral health and co-occurring medical needs.

The role is delivered within three integrated care frameworks: Provider-Delivered Care Management (PDCM), Advanced Primary Care Management (APCM), and the Collaborative Care Model (CoCM). Responsibilities include population-based caseload management using a patient registry, measurement-based treatment to target, brief evidence-based interventions, transition of care management, and medication reconciliation. The goal is to enhance patient care by addressing the complex needs of patients — particularly those with behavioral health conditions — and to ensure continuity and quality of care through effective collaboration and communication with the health care team.

Key Responsibilities

Behavioral Health Care Management

• Manage and actively follow a caseload of up to 80 patients identified for behavioral health opportunities within select practice units.

• Complete comprehensive biopsychosocial assessments and screen patients using standardized, validated tools (e.g., PHQ-9, GAD-7).

• Develop and implement individualized, patient-centered care plans in collaboration with providers, patients, and their families.

• Deliver brief, evidence-based interventions such as behavioral activation, motivational interviewing, problem-solving treatment, and relapse prevention within scope of licensure.

• Provide self-management support with a focus on empowering the patient and family to build capacity for self-care.

Collaborative Care Model (CoCM)

• Maintain and manage a behavioral health patient registry to systematically track every patient on the caseload, including patients who are not improving.

• Apply measurement-based treatment to target — track symptom scores at defined intervals and escalate or adjust the treatment plan when a patient is not responding.

• Participate in regular systematic caseload review with the consulting psychiatrist and communicate treatment recommendations back to the primary care provider.

• Support warm handoffs from the PCP and provide timely, appropriate intervention following referral for behavioral health need(s).

• Support the practice in meeting BCBSM Collaborative Care Model designation requirements, including outcomes reporting and site-visit readiness.

Provider-Delivered Care Management (PDCM) and Advanced Primary Care Management (APCM)

• Deliver care management, patient education, and coordination services face-to-face, telephonically, and virtually, consistent with PDCM and APCM program requirements.

• Use monthly PDCM patient lists, claims data, risk-stratification, and predictive-modeling flags to identify and engage patients with chronic conditions, rising risk, or emerging conditions.

• Confirm patient eligibility and obtain and document patient consent for care management services.

• Screen for social determinants of health and connect patients to community resources, benefits, and support services.

• Provide targeted interventions aimed at reducing avoidable emergency department visits and inpatient admissions.

• Support HEDIS/Stars gap closure and other quality performance measures for assigned practice units.

• Document care management time and activities accurately to support billing of applicable care management codes.

Active Care Team Member

• Actively participate in interdisciplinary care team meetings and practice huddles.

• Collaborate with physicians, advanced practice providers, nurses, pharmacists, social workers, community health workers, and other health care professionals to provide holistic, whole-person care.

• Coordinate and communicate program elements and changes to the care management team and primary care practices to support ongoing practice relationships.

Transition of Care Management

• Coordinate and manage transitions of care for patients moving between levels of care.

• Ensure seamless communication between inpatient and outpatient services, behavioral health and substance use treatment facilities, rehabilitation facilities, and home care services.

• Provide timely follow-up with the patient and family after any transition of care.

Medication Reconciliation

• Conduct thorough medication reconciliation during patient transitions.

• Identify and resolve discrepancies in medication orders and communicate concerns to the prescribing provider to ensure patient safety.

• Support patients with medication adherence, side-effect management, and access/affordability barriers.

Patient Advocacy and Support

• Function as a patient advocate, ensuring patient preferences, goals, and needs are reflected in the care plan.

• Provide education and support to patients and families regarding diagnoses, treatment plans, and health maintenance.

• Respond to inquiries from patients, practices, and payers in a timely, professional manner.

Documentation and Compliance

• Maintain accurate, timely documentation of all care management activities in the electronic health record and care management platform.

• Ensure compliance with HIPAA, 42 CFR Part 2, and related information security policies, and safeguard confidential information.

• Ensure compliance with all applicable payer, state, and federal regulations and program standards.

Quality Improvement

• Participate in quality improvement initiatives aimed at improving care coordination, integration, and patient outcomes.

• Analyze care management processes and recommend improvements.

• Contribute to program outcomes reporting for PDCM, APCM, CoCM, and PCMH initiatives.

Qualifications

Required Licensure (one of the following, current and in good standing in Michigan)

• Registered Nurse (RN)

• Licensed Practical Nurse (LPN)

• Licensed Master Social Worker (LMSW, LBSW)

• Licensed Professional Counselor (LPC / LLPC)

• Licensed Psychologist (LP / LLP / TLLP)

• Certified Alcohol and Drug Counselor (CADC / CAADC) through MCBAP

Equivalent Michigan clinical licensure or certification will be considered.

Required Training

• MICMT Certificate of Completion for Implementing Collaborative Care (“Base Training”) — the foundational MICMT course for behavioral health care managers delivering CoCM.

Required Experience and Knowledge

• Minimum of three (3) years of experience in behavioral health care, care coordination, or case management.

• Behavioral health specialized training or behavioral health practice experience within the past five (5) years.

• Working knowledge of behavioral health and substance use disorders, evidence-based treatment modalities, and integrated care principles.

• Knowledge of chronic disease management, evidence-based guidelines, prevention, wellness, risk assessment, and patient education.

• Critical thinking and assessment skills sufficient to manage complex clinical issues using protocols and evidence-based interventions.

• Proficiency with electronic health records and Microsoft Office; comfort learning new care management and registry platforms.

• Valid Michigan driver’s license, reliable transportation, and willingness to travel between practice sites.

Preferred Qualifications

• Prior experience in a primary care, ambulatory, FQHC, PCMH, or physician organization setting.

• Direct experience with PDCM, APCM, CoCM, PCMH, or BCBSM/PGIP care management programs.

• Completion of MICMT advanced CoCM coursework beyond Base Training — Implementing Collaborative Care with Adolescent and Pediatric Patients, Implementing Collaborative Care with Perinatal Patients, or Treating Substance Use in Collaborative Care Settings.

• Completion of MICMT Introduction to Team-Based Care and the BCBSM PDCM billing webinar, or willingness to complete within the first six months (required to bill PDCM codes).

• Familiarity with care management billing and CPT/HCPCS coding.

• Experience serving adult and pediatric populations.

• Experience working in a multicultural setting.

Performance Skills

• Team player who builds positive, durable working relationships with practice staff and community partners.

• Strong written and verbal communication skills; able to use plain language and active listening.

• Excellent time management, organizational, and prioritization skills; able to manage multiple and competing priorities with minimal supervision.

• Sensitive to cultural, linguistic, and psychosocial barriers to self-management.

• Creates a sense of empowerment for patients, families, and caregivers.

• Comfortable engaging new people from a wide range of backgrounds.