Care Coordinator

Integrea Community Mental Health Systems•Opelika, AL

6d•Onsite

About The Position

The Care Coordinator coordinates and integrates behavioral health, physical health, substance use disorder treatment, social services, and community-based supports for people served by Integrea. Working collaboratively with clients, families, treatment teams, healthcare providers, hospitals, community agencies, and payers, the role supports seamless, person-centered, trauma-informed care to improve health outcomes and promote recovery and wellness. Care coordination helps individuals navigate complex systems of care. This is an office-based position based in Lee County and serving Tallapoosa County and Chambers County.

Responsibilities

Coordinate behavioral health, primary care, substance use disorder treatment, and social support services for assigned individuals.
Develop, monitor, and update individualized care coordination plans with the person served, family members, and interdisciplinary treatment team.
Facilitate communication among internal and external providers to support continuity of care.
Support transitions between levels of care, including inpatient psychiatric facilities, emergency departments, residential treatment programs, detoxification programs, and community settings.
Ensure timely follow-up after hospitalization, crisis intervention, or other significant treatment events.
Participate in multidisciplinary treatment team meetings and case conferences.
Establish therapeutic and supportive relationships with individuals receiving services.
Promote client self-determination, recovery, resilience, and wellness.
Help individuals address barriers to care, including transportation, housing, insurance, employment, and access to benefits.
Educate clients and families about available services and community resources.
Advocate for individuals' needs and preferences across healthcare and social service systems.
Maintain active partnerships with healthcare providers, hospitals, federally qualified health centers, social service agencies, schools, child welfare agencies, criminal justice agencies, and other community organizations.
Facilitate referrals and track outcomes to ensure services are received.
Support outreach and engagement for individuals at risk of disengaging from treatment.
Complete required clinical and administrative documentation within established timeframes.
Maintain accurate records in the Electronic Health Record (EHR).
Track referrals, care transitions, and follow-up activities.
Ensure compliance with the CCBHC model, organizational policies, HIPAA requirements, payer requirements, and applicable federal and state regulations.
Participate in quality improvement initiatives related to care coordination and health outcomes.
Monitor performance indicators and assist in achieving CCBHC model quality benchmarks.
Use data and population health tools to identify service gaps and improve care management processes.
Perform other duties as assigned.