Behavioral health care manager (social worker)

Department Overview

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 health care 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 position requires advanced clinical skills in evidence-based assessment and intervention, with an emphasis on trauma-informed care. The BHCM must have validated training or credentialing in trauma-focused therapy and will integrate these approaches when appropriate to address the impact of trauma on health and wellbeing. Responsibilities include screening for common mental health and substance use disorders, providing psycho-education, supporting psychotropic medical management, and monitoring patient progress through systematic tracking. Additionally, the BHCM provides brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving therapy, motivational interviewing, and other treatments as appropriate. The role also involves participation in regular (weekly) caseload consultation with the psychiatric consultant and communication of resulting treatment recommendations to the patient’s continuity medical provider.

The BHCM performs duties with minimal supervision. Work is reviewed for adherence to procedures, regulations, standards and for overall effectiveness. The BHCM position is expected to serve as an advocate for collaborative behavioral health within the physical health care setting.

Function/Duties of Position

Counseling:

• Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate.
• Integrate trauma-informed and trauma-focused therapies (e.g., EMDR, TF-CBT, or other validated modalities) when clinically indicated to address the impact of trauma on patient health and functioning.
• 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.

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 soon to be discharged from the caseload.

Other Duties as Assigned

Required Qualifications

• A Master’s Social Work (MSW) required. Health care experience preferred.
• 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 conceptualize patient psychopathology.
• Skill and expertise in conducting group and individual psycho-educational classes and brief, short-term therapy strategies that will help strengthen the patient's overall physical and mental health.
• Incorporation of self-management, home-based practice in care planning.
• Skill in efficiently organizing time so that unscheduled, same day services are routinely available to care team members.
• The ability to exercise sound judgment in appraising situations and making decisions regarding complex physical and behavioral health treatment issues in consultation with the primary care teams.
• Skill in developing effective working relationships with peers, supervisors, and professionals in related disciplines.
• Ability to manage complex personal interactions.
• Demonstrated ability to act with minimal supervision on personal initiative using sound clinical judgment.
• Strong written and verbal communication skills.
• Ability to maintain confidentiality regarding patient care information and chart contents as use of patient record and privacy of individuals must be protected to the fullest.
• Ability to maintain documentation in compliance with State, Federal, Professional and Ethical guidelines.

Preferred Qualifications

• Training in Primary Care Behavioral Health
• Health care experience
• Experience in behavioral health counseling and brief short-term therapy strategies and case management in an ambulatory setting.
• Experience and/or interest in Collaborative Care.
• Experience in a Primary Care Ambulatory Clinic setting.
• Experience with program development and evaluation.
• 3 years’ experience in similar position

Additional Details

Hours: Variable. Five 8-hour shifts, Monday-Friday, with possibility of evening or weekend hours. Flexing start/end times to accommodate clinical needs may provided, as well. The work is performed in a medical setting and involves normal working hours with occasional alternative hours for special programs or outreach. The position involves interactions with people who have a wide variety of physical and behavioral health problems. Some travel may be required.

Posted 12/3/2025 3:58pm

Why apply to OHSU?

We are Oregon's only public academic health center. In addition to caring for patients, we lead groundbreaking research. We also train the next generation of health care professionals. As Portland's largest employer, we give you opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington. All are welcome. OHSU welcomes people of all ages, ethnicities, genders, national origins, religions and sexual orientations. We are striving to build an anti-racist, multicultural institution and encourage people with diverse backgrounds to apply. To request reasonable accommodation, contact askhr@ohsu.edu