Integrated Care Coordinator

Integrated Care Coordinator

The Integrated Care Coordinator supports patients with complex medical, behavioral health, and social needs by coordinating services across primary care, behavioral health, substance use disorder treatment, and community resources. The coordinator serves as a central point of contact for patients enrolled in programs such as Medication for Opioid Use Disorder (MOUD/MAT), Substance Use Disorder Health Home (SUDHH), justice-involved initiatives, and other high-risk populations. This role promotes engagement in care, addresses barriers to treatment, and facilitates communication among interdisciplinary team members to improve health outcomes.

Specific duties and job functions:

1. Coordinate medical, behavioral health, dental, specialty, and community-based services to ensure continuity of care.
2. Assist patients navigating the healthcare system, accessing resources, and resolving barriers to care.
3. Facilitate referrals, schedule and confirm appointments, and close referral loops within 14 days whenever possible.
4. Coordinate transitions of care following hospitalization, incarceration, detoxification, residential treatment, or emergency department visits, including follow-up within 7 days.
5. Conduct outreach via phone, text, and mail to engage, re-engage, and retain patients in care.
6. Reduce no-show rates through appointment reminders, barrier assessments, and problem-solving.
7. Develop, update, and monitor individualized care plans in collaboration with the interdisciplinary team; update plans every 90 days or as required.
8. Complete required assessments and maintain timely, accurate documentation in the electronic health record, with documentation completed within 24 hours.
9. Monitor patient participation, goals, treatment progress, and risk of disengagement.
10. Connect patients to housing, transportation, food, employment, insurance, legal, and recovery resources.
11. Assist with enrollment and engagement in MAT, SUDHH, justice-involved, and other applicable programs.
12. Support program census growth through outreach, referral follow-up, and patient engagement.
13. Track outreach, referrals, care plans, follow-up activities, and required program metrics.
14. Participate in interdisciplinary team meetings and case conferences and communicate with healthcare providers, behavioral health staff, peer support specialists, CHWs, correctional partners, hospitals, and community agencies.
15. Ensure compliance with HRSA, Medicaid, grant, payer, and organizational requirements.
16. Manage a caseload of approximately 50–100 active patients, depending on program complexity.
17. Maintain compliance with required care plan completion and program documentation standards.
18. Document all outreach attempts within 24 hours and maintain accurate tracking of patient engagement and follow-up activities.

Knowledge, skills, and abilities:

• Knowledge of Medication Assisted Treatment for Substance Use Disorders.
• Knowledge of Evidence Based Practice models and multiple pathways to recovery.
• Conflict resolution skills and facilitation skills.
• Exceptional communication skills, both written and verbal.
• Comfortable with public speaking.
• Knowledge of the nonprofit environment.
• Able to work independently yet seek resources or team assistance when needed.
• Experience handling a variety of responsibilities and projects.
• Able and willing to assist with training of volunteers that may be needed.
• Good organizational skills. Able to coordinate multiple tasks well.
• Knowledge of Macomb County and neighboring community resources.
• Proficiency in the use of Microsoft Office.
• Flexible hours to accommodate patient services when required.
• Willingness to creatively and innovatively problem-solve alongside patients and populations.

Personal attributes:

• Must be honest and trustworthy, respectful of others.
• Must be flexible and possess cultural awareness and sensitivity.
• Must possess excellent written and oral skills.

Academic education or equivalent requirement:

Associate degree in social work, human services, behavioral health, healthcare administration, public health, or related field required. Bachelor's degree preferred. An equivalent combination of education and relevant experience in healthcare, behavioral health, substance use disorder services, care coordination, or case management may be considered.

Qualifications:

• Demonstrate competence in working cooperatively with physicians and other health care professionals.
• Commitment to the corporate Mission Statement.
• Must maintain up to date CPR (BLS) certification.

Benefits:

• Student loan forgiveness programs (based on position and available federal programs)
• 11 Paid Holidays Annually (1 floating)
• Up to 160 hours of annual PTO (based on start date)
• Affordable premiums for medical, dental, and vision insurance coverage for individuals and families
• No cost life insurance coverage (additional coverage optional for a fee)
• Long term disability insurance
• 401K and Roth 401k retirement plans with discretionary employer match
• Flexible Spending Account (FSA)
• Short term disability insurance (optional for a fee)
• Employee Assistance Program (EAP)

MyCare Health Center is an Equal Opportunity Employer. Applicants will be considered for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristics protected by applicable law.