Care Coordination

Spero•Owatonna, MN

12h•$19 - $21•Hybrid

About The Position

The CCBHC Care Coordinator is responsible for coordinating and supporting integrated, person-centered services for individuals receiving care through the Certified Community Behavioral Health Clinic (CCBHC). This position works collaboratively with clients, families, behavioral health providers, primary care providers, social service agencies, and community partners to ensure individuals have timely access to appropriate services and resources. The Care Coordinator serves as a consistent point of contact for clients and helps facilitate communication across providers and systems. The position supports individuals in navigating behavioral health, medical, social, and community-based services while promoting engagement in care, continuity of services, and improved outcomes.

Requirements

Cultural Humility: The ability to work effectively with diverse populations and understand the social determinants of health affecting them.
Motivational Interviewing: Ability to engage clients and help them navigate their own goals for recovery and health.
Excellent interpersonal communication skills; deals effectively with a variety of people and personalities; communicates clearly and effectively both orally and in writing.
Able to work independently, showing initiative, and willingness to take charge of a situation.
Skilled in identifying and assessing a wide range of clients’ needs.
Applies effective time management skills in order to meet all deadlines.
Daily local travel may be required; candidates must have the physical ability to operate a motor vehicle safely and must possess a valid driver’s license.

Responsibilities

Assist clients in accessing and navigating behavioral health, primary care, substance use, social service, and community resources.
Maintain regular communication with clients to assess needs, identify barriers to care, and support progress toward established goals.
Coordinate communication and information-sharing among internal providers and external agencies, consistent with applicable consent, privacy, and confidentiality requirements.
Facilitate and follow up on referrals to ensure client is receiving all recommended services.
Support transitions of care, including hospital discharges, crisis services, residential services, and other changes in level of care.
Participate in multidisciplinary treatment team meetings and collaborate with providers to identify and address gaps in care.
Identify individuals who may be at increased risk for disengagement from services and implement appropriate outreach and follow-up.
Document care coordination activities, contacts, referrals, outcomes, and other required information accurately and in a timely manner.
MA renewal and eligibility support: Identify, assist and follow up for clients who have benefit renewals or new eligibility requirements.