Integrated Care Coordinator

Overview: Join Our Impactful Team at Health Connect America! Health Connect America and our family of brands are leading providers of mental and behavioral health services for children, families, and adults across a multi-state footprint. As a COA-accredited organization, we are held to nationally recognized standards of quality, accountability, and best practice in every aspect of care we deliver. We are relentlessly committed to keeping families together and transforming lives through evidence-informed care, delivered by clinically trained staff who meet clients where they are — in their homes, in their communities, and in our offices. Our work is guided by five core values: client-centered care, empowerment of our people, evidence-informed excellence, a purpose-driven culture, and bold, adaptive leadership. When you join Health Connect America, you join an organization that invests in you. You'll Grow With Us through meaningful development opportunities, Be Well With Us through programs that support your whole self, and know that You Belong With Us in a culture built on purpose, compassion, and impact. Our Brands Responsibilities: The primary responsibilities of the Integrated Care Coordinator are to deliver comprehensive, person-centered care by planning, coordinating, and monitoring individualized treatment plans to align with behavioral health goals. They play a pivotal role in closing gaps, tracking progress, and upholding the highest standards of quality and regulatory compliance. Assist the Nurse Practitioner with clinic appointment related documentation and facilitation on site when working in the clinic. Additionally, they support marketing initiatives for new referrals and engage in outreach to integrated care attributed members, providing education on our program, and facilitating enrollment. Actively engage with individuals through assessment, coordination, health promotion, and transitional care, documenting assessments and coordinating with the care team and treatment teams. Provide comprehensive care management, coordination, health promotion, individual and family supports, and referrals to community services. Complete the Care Management Comprehensive Assessment within designated timeframes and share results with primary care providers and relevant agencies. Ensure clients receive required physical exams, medication monitoring, and appropriate services. Maintain medical record compliance and ensure timely documentation of care coordination activities. Monitor HEDIS gaps and verify client payer and program enrollment status monthly. Develop individualized, person-centered care plans incorporating assessment results and Division’s guidelines, focusing on unmet health needs and Social Determinants of Health (SDOH). Coordinate follow-up services for recent hospitalizations or life transitions, ensuring smooth transitions of care. Identify and provide crisis response as necessary, participate in post-crisis debriefing, and be available for on-call support. Communicate effectively with individuals, providers, and natural supports, providing education on services. Establish collaborative relationships with care team members and community resources to improve resource linkage and documenting follow-up. Support transitions between care settings and develop comprehensive discharge or transition plans. Attend Treatment Team and supervision meetings, integrated care team meetings, and serve as a liaison with other professionals and agencies. Assist with marketing new client referrals and provide on-call support as needed. Review data for service appropriateness and compliance issues. Attend training sessions and comply with agency policies and procedures. Ensure compliance with all state regulatory requirements. Responsible to the following when based in a clinic: Facilitate on-site clinic operations including but not limited to maintaining office clinic schedule, complete clinic reminder calls, taking and documenting client vitals, completing clinic chart documentation, and integrated care services for all clinic clients, especially integrated care clients only in med management program. Manage and maintain Integrated Care and Clinic Roster for the office including tracking and management of clinic census that matches census in Carelogic. Provide health education resources to med management clients regarding diagnoses and medications given by Nurse Practitioner. Qualifications: Qualifications may vary by state due to differing regulations and standards in mental and behavioral health services. TN: A Bachelor’s Degree in any discipline is required, with a preference for degrees in human services or related fields essential for careers in mental and behavioral health. Experience working with children and families in case management type/ community resource position. NC: Minimum of one of the following qualifications to meet criteria as a Qualified Professional (QP). Per 10A NCAC 27 .0104 a MH/SU license (including associate-level), or are certified by the NC Substance Abuse Board or, a RN AND have four years of full-time experience working with the MH/SU/IDD population or, a master’s degree in a human service field AND at least one year of full-time experience working with the MH/SU/IDD population or, a bachelor’s degree in a human service field AND at least two years of full-time experience working with the MH/SU/IDD population or, a bachelor’s degree in a non-human service field AND at least four years of full-time experience working with the MH/SU/IDD population. Two years of experience working directly with individuals with behavioral health conditions (if serving members with behavioral health needs). *For care managers serving members with LTSS needs: Two years of prior LTSS and /or HCBS coordination, care delivery monitoring, and care management experience, in addition to the required cited above. (This experience may be concurrent with the two years of experience working directly with individuals with behavioral health conditions, an I/DD, or a TBI, above.) Be Well with HCA: We recognize the importance of self-care and work/life balance. We offer flexibility in scheduling and provide all employees access to our Employee Assistance Program (EAP), which includes 8 mental health counseling sessions annually. Full-time HCA employees enjoy paid time off, paid holidays, and a comprehensive benefits package that includes medical, dental, vision, and other voluntary insurance products. Additional benefits include: Access to a Health Navigator Health Savings Account with company contribution Dependent Daycare Flexible Spending Account 401(k) Retirement Plan Benefits Hub Tickets at Work Join a team where your contributions truly make a difference in the lives of others. Apply now to be part of our dynamic and supportive community at Health Connect America! Employment at Health Connect America and it's companies is contingent upon meeting the requirements of a comprehensive background investigation prior to joining our team. Health Connect America and its companies are an Equal Opportunity Employer and consider applicants for employment without regard to race, color, religion, sex, orientation, national origin, age, disability, genetics, or any other basis forbidden under federal, state, or local law. For more information on Equal Opportunity, please click here Equal Employment Opportunity Posters