Family Medicine at South Waterfront is a community based clinic offering primary care and specialty services for all types of patients. We treat everyone--babies, children, adolescents, adults (including moms-to-be), and seniors. Our services include prenatal care (including deliveries), women's reproductive health, behavioral health care and counseling, transgender care, pediatric care, travel immunizations, podiatry and foot care clinics, sports medicine, Osteopathic Manipulative Treatment (OMT), Office Based Medication Assisted treatment (OBAT), acupuncture, minor procedures, and health maintenance with preventive care. Between 175 and 275 patients are seen daily by our 40 plus providers assisted by 60 plus staff members.

 

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.

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

• 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. 

• 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

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 4:01pm

Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.