This is my current role, I currently work to meet the SDOH needs and track data for SDOH.
Position Summary:
The Behavioral Health Care Manager (BHCM) is integrated within a primary care clinic to function as a member of the multi-disciplinary team to effectively manage referrals and coordination of care for patients, focus on social determinants of health and other needs that may impact health and wellbeing, provide patients and their supports with education, and helping patients navigate health and social services systems.

Knowledge, Skills and Abilities:
• Knowledge of:
o Community resources and placement options for mental health, substance use disorders, and social determinants of health
o Laws, policies, and regulations regarding mental health and substance use disorder treatments
o Integrated care practices and procedures
• Skills:
o Scheduling/confirmation of behavioral health appointments within the primary care clinic
o Coordinate and monitor specialty mental health and substance use disorder treatment referrals
o Identify psychosocial barriers that would prevent adherence to referrals and impact overall health and facilitate referrals to available community resources and supports
o Provide care management services to identified patients
o Educate patient and supports on self-care and self-management to enhance self-efficacy
o Facilitate access to educational materials for patients and supports
o Assist with tracking data for grant reporting and quality improvement
o Facilitate communication between primary care and specialty care providers as needed
• Abilities:
o Demonstrate strong organizational and computer competency
o Provide clear and concise documentation
o Promote community collaboration with Integrated Health Care services through participation in community forums (health fairs, task groups, multi-agency behavioral health initiatives and other community and agency functions)
o Demonstrate cultural competency in serving diverse populations
o Demonstrate practical application of case management knowledge
o Track and update EHR based on outcomes of assessments, resources and referrals provided
• Other duties as assigned

Clinical Goals:
• Improve patient adherence to healthcare goals
• Support patient self-management of conditions and/or risk factors
• Agent of behavioral change
• Decrease over or under utilization of health services
• Reduce health-risk behaviors and increase health enhancing behaviors
• Monitor and improve population outcomes
Quality Improvement:
BHCs must understand and help enforce the meaning of quality improvement identified as the combined and unceasing efforts of everyone – healthcare professionals, patients, and their families, researchers, payers, planners and educators – to make the change that will lead to better patient outcomes, better system performance and better professional development (Batalden 2007). BHCs will demonstrate commitment to promoting TAPM as a medical home and incorporating the core components of a Patient Centered Medical Home into your position on a daily basis:
1. Patient centered
2. Comprehensive care
3. Team based
4. Coordinated
5. Accessible
6. Focusing on quality and safety

System Wide Accountabilities:
• Maintain a professional appearance
• Demonstrate a positive attitude
• Maintain a safe, clean and attractive environment
• Communicate with compassion and courtesy
• Anticipate needs of customers and others
• Maintain patient privacy and confidentiality

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