• Provides care to patients, based on needs of assigned Care Pod, customizing treatment plan to individual patient needs • Supports and closely coordinates behavioral health care with the patient’s primary care provider and (when appropriate) other service providers • Screens patients for common behavioral health and substance use disorders using PHQ9, GAD7, Columbia Suicide Risk Assessment, or other tools as required • Monitors patients for changes in clinical symptoms and treatment side effects/complications, with a goal of reduction in symptoms • Supports psychotropic medication management prescribed by PCPs, focusing on treatment adherence, side effects and other complications, and treatment effectiveness • Tracks patient follow-up and clinical outcomes using a registry, records encounters in the registry and uses the system to identify and re-engage patients • Plans specific mutual self-management goals, objectives, and interventions with action-oriented patients • Facilitates care plan changes for patients who are not improving, including changes in medications or psychosocial treatments or appropriate referrals for additional services • Documents patient progress and treatment recommendations in Salesforce and the electronic health record so they can be easily shared with primary care providers, the psychiatric consultant, and other treating providers • Completes relapse prevention plan with patients who are in remission • Educates patients about behavioral health/substance use disorders and treatment options • Establishes mutually agreeable care management plan with the care team and patient/family • Participates in regularly scheduled caseload consultations with psychiatric consultants • Participates in regularly scheduled supervision sessions with clinical supervisor • Identifies social determinant barriers and works alongside the Care Navigation Partner to assist in providing access to the correct level of internal or external care