Responsibilities will include:
- Lead our integrated behavioral health service which closely aligns with the evidence-based Collaborative Care Model, for all patients with mild/moderate behavioral health needs including substance use disorder
- Lead bridge services for patients with serious mental illness (e.g., schizophrenia, bipolar disorder) and/or substance use disorder, providing short-term (3–6 month) stabilization and transitioning patients to long-term community care
- Lead low intensity services for patients with mild concerns not requiring higher-intensity care, offering brief (1–3 session) interventions, coordinating psychiatric eConsults, and referring to community services as needed
- Support patients with severe mental illness and severe substance use disorders in our Advanced Behavioral Health program in conjunction with our behavioral health team and health advocates
- Engage eligible patients, develop and execute individualized, measurement-based treatment plans focused on symptom remission or reduction, and track progress in a care registry (most patients complete the program within 6–12 months)
- Conduct outreach and patient engagement, intake assessments, and treatment planning with psychiatrists and psychiatric advanced practice clinicians
- Deliver brief, evidence-based interventions and short-term therapy
- Monitor outcomes, coordinate care with primary teams, and connect patients to community resources
- Support transitions of care by coordinating discharge plans, assessing readmission risk, ensuring follow-up, and connecting services post-facility discharge
- Provide behavioral health triage for urgent issues and participate in multidisciplinary case conferences and clinical rounds
- Educate and support teams through coaching on behavioral health best practices and facilitating resilience sessions for staff well-being
- Contribute to program improvement by offering feedback on workflows, ensuring high-quality care delivery, and maintaining timely documentation
- Conduct pre-visit chart preparation by reviewing external medical records (via HIEs and other sources) while using clinical judgment to identify and validate behavioral health conditions
- Potential for travel to the local market for onboarding (1 week) and quarterly training/team-building (1–2 days)
- Performs other duties as assigned
What makes you a fit for the team:
- Passionate about serving complex, historically underserved patients with co-occurring chronic and behavioral health conditions through an integrated, home-based, and virtual care model
- Dedicated to delivering high-quality, patient-centered care and ensuring an exceptional healthcare experience for every patient
- Eager to contribute to and grow within an innovative, rapidly evolving care model
- Committed to continuous learning and improving workflows to enhance patient outcomes
- Strong communicator skilled in coaching and mentoring multidisciplinary team members
- Comfortable providing short-term therapy, care management, and diagnosis/treatment across mild to severe mental illness, including substance use disorders
Desired skills and experience:
- Required
- Active LICSW, LCSW, LMHC, or LPC license in the state of employment and willingness to obtain additional licensure as requested
- 5+ years of clinical experience in assessment, diagnosis, planning, and management of behavioral health care, including direct therapy and care management
- 2+ years working with high-risk populations with serious mental illness and substance use disorders
- Skilled in trauma-informed and culturally sensitive care
- Ability to provide brief psychotherapeutic techniques in sessions as short as 15-30 minutes
- Skilled and comfortable assessing and supporting patients with severe mental illness, collaborating with a psychiatrist or psychiatric APC on diagnoses such as bipolar disorder, PTSD, schizoaffective disorder, schizophrenia, and substance use disorders
- Adaptability with technology and ability to become proficient in multiple external electronic medical records to access patient records
- Familiarity with DSM-5 diagnostic criteria
- Experienced in interdisciplinary collaboration, especially with health advocates and primary care providers
- Flexible, adaptable, and eager to learn and improve processes
- Preferred
- 1+ years in the Collaborative Care (CoCM) model
- 2+ years in care/case management, preferably in ambulatory or community settings serving high-risk populations
- Experience in transitions of care management for behavioral health discharges, including medication reconciliation, patient education, and care navigation
- Knowledge of Medicare, Medicaid, and local behavioral health resources
- Participation in quality improvement initiatives
- Proven ability to build and maintain relationships with healthcare and community partners