Collaborative Care Behavioral Health Care Manager

Overview

In 1971, Yale University established Yale Health to provide health services to its facility, staff and students through a multidisciplinary health maintenance organization located on campus. Yale Health has more than 50,000 members including students, staff, faculty and their families who come from every state in the country and almost every country in the world. With over 50 years of service to the Yale community, our state‑of‑the‑art facility at 55 Lock Street is where our members receive most of their care from our 150+ providers.

It is a 144,000 square foot medical facility with over 90 exam rooms, an Acute Care Department, a 15‑bed inpatient facility with two negative pressure rooms, a diagnostic imaging suite including MR and CT scan, x‑ray and ultrasound and a full‑service retail pharmacy.

Support the behavioral and physical health care of patients on an assigned caseload; closely coordinate care with medical providers, psychiatric consultant, and other care team members. Collaborate with Internal Medicine and OB/GYN clinicians to develop and implement integrated care plans. Facilitate referrals to specialty mental health, substance use treatment, and community‑based services as clinically indicated (e.g., social services, perinatal supports).

Screen and assess patients for common mental health and substance use disorders using validated tools (e.g., PHQ‑9, GAD‑7, EPDS). Conduct clinical assessments, including risk assessment and safety planning as appropriate. Facilitate patient engagement in treatment and ensure ongoing follow‑up care. Provide patient education on mental health conditions and available treatment options.

Systematically track treatment response and monitor patients (in person and/or via telephone/virtual care) for changes in symptoms, treatment adherence, and side effects. Maintain and utilize a patient registry or equivalent system to track clinical outcomes and identify patients requiring outreach. Proactively follow up with patients who are not improving or who are lost to follow‑up. Document all patient encounters and clinical data in the electronic health record and registry systems.

Provide brief, evidence‑based behavioral interventions (e.g., behavioral activation, problem‑solving treatment, motivational interviewing). Support psychotropic medication management prescribed by medical providers by monitoring adherence, effectiveness, and side effects. Reinforce treatment plans and promote patient self‑management strategies.

Participate in regular (typically weekly) caseload consultation with the psychiatric consultant. Present new and complex cases, as well as patients not improving as expected. Communicate psychiatric treatment recommendations to medical providers and support implementation. Facilitate treatment plan adjustments using stepped‑care principles.

Facilitate transitions to higher levels of care when clinically indicated. Develop relapse prevention and self‑management plans for patients achieving treatment goals. Support planned discharge from the CoCM caseload.

Document patient progress, assessments, and treatment plans in accordance with organizational and CoCM requirements. Support adherence to Collaborative Care workflows, including population‑based care delivery and outcome tracking. Participate in program development, quality improvement initiatives, and team‑based care processes. Perform additional responsibilities as assigned.

Full‑time; 37.5 hours; weekdays, flexible schedule. Generally Monday – Friday, between 8:30 a.m. – 5:00 p.m.; may be required to work evenings, weekends or holidays. May participate in on‑call rotation.