Behavioral Health Case Manager

Reports To: Manager of Supportive Services

Location: Caroline Clinic, Cathedral Clinic, Reed Family Clinic, PSH Sites 

Overview The Behavioral Health Case Manager serves as a key member of an interdisciplinary care team, providing comprehensive case management services to individuals experiencing behavioral health conditions, substance use disorders (SUD), opioid use disorder (OUD), co-occurring mental health and substance use conditions, chronic medical conditions, housing instability, and other social determinants of health. Working within an integrated primary care setting, this position focuses on supporting recovery, reducing barriers to treatment, coordinating care across multiple systems, and promoting long-term wellness through a harm reduction and recovery-oriented framework. 

The Behavioral Health Case Manager functions as a liaison between patients, healthcare providers, behavioral health professionals, community organizations, housing programs, and social service agencies to ensure seamless, person-centered care. This position plays a critical role in supporting patients enrolled in Medication-Assisted Treatment (MAT) services by facilitating treatment engagement, monitoring service participation, coordinating referrals, supporting relapse prevention efforts, and helping patients navigate recovery resources. The position collaborates closely with primary care providers, behavioral health clinicians, psychiatrists, peer recovery specialists, and community-based treatment providers to ensure continuity of care throughout the recovery process.

Duties and Responsibilities

Case Management and Care Coordination

• Conduct comprehensive biopsychosocial assessments to identify patient strengths, needs, barriers, risks, and support systems.
• Develop individualized service plans in collaboration with patients, providers, and community partners to address behavioral health, medical, housing, employment, financial, and social service needs.
• Coordinate care across multiple service systems, including primary care, behavioral health, substance use treatment, housing, social services, and specialty medical providers.
• Monitor patient progress toward treatment and recovery goals through ongoing engagement, reassessment, and follow-up.
• Provide intensive case management for patients with complex medical, behavioral health, and social needs.
• Facilitate referrals and linkage to community resources, including mental health services, substance use treatment, housing, transportation, food, benefits enrollment, vocational programs, and other supportive services.
• Advocate on behalf of patients to reduce barriers to care and improve access to services.
• Assist patients in navigating healthcare systems, insurance, public benefits, and community-based programs.
• Participate in interdisciplinary case reviews and collaborative care meetings to ensure continuity of care and effective treatment planning.

Substance Use Recovery and Behavioral Health Support

• Provide case management to individuals with substance use disorders, opioid use disorder, alcohol use disorder, stimulant use disorder, and co-occurring behavioral health conditions.
• Coordinate services for patients in Medication-Assisted Treatment (MAT) programs, including appointment scheduling, treatment engagement, referral coordination, and ongoing recovery support.
• Conduct substance use screenings and assist with assessment of treatment needs using evidence-based tools.
• Support patients across the continuum of substance use treatment, including detoxification, residential treatment, IOP, outpatient treatment, recovery housing, and peer recovery services.
• Utilize motivational interviewing and stages-of-change principles to enhance treatment engagement and readiness for recovery.
• Assist patients in identifying recovery goals and developing individualized relapse prevention and recovery maintenance plans.
• Coordinate referrals to community-based substance use treatment providers and recovery support organizations.
• Educate patients and families on substance use disorders, overdose prevention, harm reduction, recovery resources, and available treatment options.
• Facilitate access to naloxone education and overdose prevention resources when appropriate.
• Support patients experiencing relapse through nonjudgmental engagement, reassessment, and rapid linkage to appropriate services.
• Collaborate with MAT providers, behavioral health clinicians, psychiatrists, peer recovery coaches, and community partners to promote sustained recovery and treatment retention.
• Monitor patient progress, treatment participation, and recovery outcomes through ongoing follow-up and care coordination.
• Facilitate psychoeducational groups focused on relapse prevention, coping skills, recovery maintenance, wellness, and substance use education.
• Promote a harm reduction, trauma-informed, and recovery-oriented approach in all patient interactions.

Patient Advocacy and Community Collaboration

• Establish and maintain therapeutic, professional relationships with patients and families.
• Serve as a patient advocate in interactions with healthcare providers, housing agencies, social service organizations, and community partners.
• Collaborate with internal and external stakeholders to address social determinants of health and improve patient outcomes.
• Promote equitable access to services through culturally responsive and trauma-informed care practices.
• Support initiatives aimed at reducing health disparities and improving quality of life for vulnerable populations.

Documentation, Compliance, and Quality

• Complete timely, accurate, and compliant documentation in the electronic health record, including assessments, treatment plans, progress notes, and discharge summaries.
• Maintain clinical documentation in EPIC and CMBHS in accordance with HIPAA, Medicaid, grant requirements, and state licensing standards.
• Monitor patient progress and adjust treatment plans based on clinical response and engagement.
• Track outcomes and contribute to quality improvement initiatives and program evaluation.
• Maintain required reports, caseload data, and service metrics.

Support HHH Mission

• Demonstrates a commitment to HHH’s mission of promoting health, hope, and dignity for individuals experiencing homelessness through equitable and compassionate care.
• Upholds trauma-informed, culturally responsive, and patient-centered principles in all interactions, contributing to an inclusive and supportive environment for patients and team members.
• Actively contributes to a culture of collaboration, accountability, and innovation in service of our goal to eliminate health disparities and advance systems-level change.

Minimum Qualifications 

• Associate's or Bachelor's degree in Social Work, Human Services, Psychology, Sociology, Criminal Justice, or a related field
• Minimum of one (1) year of experience in case management, social services, behavioral health, substance use treatment, healthcare, or community-based services
• Experience working with high-need, underserved, or homeless populations
• Knowledge of community resources, service systems, and care coordination practices
• Strong clinical assessment, crisis intervention, and advocacy skills
• Ability to work effectively across clinic-based and community-based settings
• Excellent verbal, written, and interpersonal communication skills
• Strong organizational skills with the ability to manage multiple priorities while maintaining attention to detail
• Proficiency with Microsoft Office applications and electronic health record (EHR) or electronic documentation systems
• Ability to utilize telehealth and virtual communication platforms (e.g., Zoom, Microsoft Teams, WebEx)

Preferred Qualifications

• Master's degree in Social Work, Counseling, Psychology, or a related field
• Current Licensed Chemical Dependency Counselor (LCDC) or LCDC-Intern (LCDC-I) working toward full licensure
• Experience supporting Medication-Assisted Treatment (MAT) or Medications for Opioid Use Disorder (MOUD) programs
• Knowledge of ASAM levels of care, recovery support services, and community treatment resources
• Familiarity with harm reduction practices, overdose prevention, naloxone education, and recovery-oriented systems of care
• Experience collaborating with residential treatment providers, detoxification programs, recovery housing programs, and peer recovery organizations
• Bilingual in English and Spanish