UVA Health·Culpeper, Virginia
The Behavioral Health Navigator coordinates care for patients within the Collaborative Care Model, providing brief evidence-based interventions for mental health and behavioral concerns. They collaborate with primary care providers and psychiatric consultants to monitor treatment progress and facilitate necessary referrals.
UVA Health is seeking a full-time Behavioral Health Navigator (MSW – Master of Social Work) to support patients at UVA Health Primary Care Culpeper and UVA Health Pediatrics Culpeper.
This is an in-person position, with time split evenly (50/50) between the two clinic locations. The Behavioral Health Navigator will work collaboratively with care teams to support both Family Medicine and Pediatric patients and their families.
The Behavioral Health Navigator is a core member of the primary care team supporting the implementation of the Collaborative Care Model, along with the patient’s primary care provider and psychiatric consultant.
The Behavioral Health Navigator is responsible for support and coordinating care for patients enrolled in Collaborative Care Model services, assisting with the provision of brief evidence-based, condition-specific, protocol-driven services in treating common mental health and health behavior concerns in primary care (e.g. depression, anxiety, attention/behavior problems, trauma, suicide risk).
The majority of the Behavioral Health Navigator's time will be reserved for Collaborative Care Model activities; as time permits, the Behavioral Health Navigator will assist the general clinic population with addressing needs related to social determinants of health.
PRINCIPAL DUTIES AND RESPONSIBILITIES: Essential Functions of the Job: Engage with patients enrolled in collaborative care management of behavioral health conditions.
Screen patients for common mental health and substance abuse disorders included in Collaborative Care Model pathways.
Provide patient education about common mental health and substance abuse disorders and the available treatment options.
Support psychotropic medication management as prescribed by primary care providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.
Conduct outreach for patient engagement and follow-up care.
Provide brief behavioral interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments as appropriate.
Develop and complete relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to complete their course of care.
Monitor patient progress and response to treatment Systematically track treatment response and monitor patients (in person or by telephone) for changes in clinical symptoms and treatment side effects or complications.
Track patient follow up and clinical outcomes using a registry.
Document in-person and telephone encounters in the registry and use the system to identify and re-engage patients.
Document patient progress and treatment recommendations in EHR and other required systems so as to be shared with primary care providers, psychiatric consultant, and other treating providers.
Team collaboration and care coordination Participate in regularly scheduled (usually weekly) caseload consultation with the psychiatric consultant and communicate resulting treatment recommendations to the patient’s primary care provider.
Consultations will focus on patients new to the caseload and those who are not improving as expected under the current treatment plan.
Case reviews may be conducted by telephone, video, or in person.
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.
Provide or facilitate in-clinic or outside referrals to evidence-based psychosocial treatments as clinically indicated (mental health specialty care, substance abuse treatment).
Facilitate referrals for clinically indicated services outside of the organization to address social determinants of health (e.g., social services such as housing assistance, vocational rehabilitation).
Serve as clinic liaison to schools and other outside agencies for psychosocial topics and care coordination.
Non-Essential Functions of the Job: Ability to remote work during inclement weather/modified clinic operations
Candidates must hold a Master's degree in Social Work from a CSWE accredited program and obtain BLS Certification within 90 days of hire. Experience in screening for mental health and substance abuse disorders is required.
Market context
Behavioral-health roles in Virginia commonly draw steady demand as agencies and treatment programs look for clinicians who can support counseling, care coordination, and recovery services. These positions are competitive because a valid CSAC license is required, while a psychology or counseling degree and treatment-industry experience are preferred; benefits often include PTO and health-related coverage. Review the AI-summarized requirements and benefits on this platform to save time, and confirm your licensure details before applying.
