Care Team Specialist - Nebraska CCBHC

Heartland Family Service•Omaha, NE

49d•$20 - $24

About The Position

The Care Team Specialist (CTS) is a care coordination role within the Certified Community Behavioral Health Clinic (CCBHC) model responsible for supporting timely access, engagement, and continuity of care for individuals receiving mental health and/or substance use services. The CTS serves as a central coordination point to identify care team members, address barriers to service access, and facilitate communication across medical, behavioral health, substance use, and community support systems. This role includes direct client engagement to support care coordination and continuity. The CTS focuses on maintaining system-level alignment, monitoring engagement, identifying gaps in care, and connecting clients to the appropriate level of ongoing support.

Requirements

Bachelor’s degree in social work, psychology, sociology, human services, or related field (or comparable experience)
Demonstrated ability to engage clients and communicate effectively with providers
Basic computer and documentation skills
Strong communication skills with providers and community partners
Ability to work within a multidisciplinary, team-based care model

Nice To Haves

One (1) year experience in health, behavioral health, or human services preferred

Responsibilities

Serve as an initial point of contact to build rapport and assess client needs related to access, coordination, and engagement in services.
Identify existing care team members, including medical, behavioral health, substance use, social service, and natural supports, and when such supports are not yet in place, identify and facilitate connections to appropriate resources and care team members.
Monitor client engagement and service connectivity, including follow-up on missed appointments, transitions of care, and emerging barriers.
Coordinate care during transitions, including hospital discharge, crisis stabilization, or changes in provider level of care.
Ensure completion of required CCBHC-aligned assessments and, when appropriate and within scope, administer designated screening tools to support access and coordination.
Contribute (LEAD) the development and updating of individualized care coordination plans in collaboration with the client and providers, identifying strengths, needs, goals, and service alignment. (Does not replace clinical treatment planning.)
Assist clients with referrals, releases of information, and warm handoffs to appropriate services.
Facilitate communication among providers, internal teams, and support networks to promote continuity and shared understanding of care goals.
Support timely access to services by coordinating referrals, releases of information, and warm handoffs.
Identify gaps in services or access and advocate for connection to appropriate community resources.
Coordinate case review conferences or care team communication when appropriate.
Complete and maintain accurate, timely documentation in accordance with agency and state standards that are audit ready.
Maintain episodic, purpose-driven contact with clients to confirm care connections.
Identify when client needs exceed the CTS scope and escalate to targeted case management or other appropriate services. May provide short-term, crisis-responsive case management while facilitating referral and transition to other appropriate services.
Build and work within a multidisciplinary team, utilizing team expertise appropriately.
Maintain professional relationships with community providers and service partners.
Identify gaps in care, access, or coordination and facilitate connection to appropriate services and care team members to advocate for client needs where necessary.
Support agency efforts to build community connections that enhance access to care.
Some community-based coordination and provider communication may be required.
Agrees to always display a courteous and caring attitude to the clientele, volunteers, and visitors of the Agency.
Cooperates and collaborates with program area staff, volunteers, and other Agency staff.
Is dependable and punctual regarding scheduling and attendance.
Abides by all specific program and Agency procedures, policies, and requirements.
Develops personal and program related skills through participation in internal and external training opportunities including printed material and audio and/or visual media.
Creates, maintains, and shares an appropriate and dynamic self-care plan.
Essential functions are performed on-site or in designated workspaces. Some work may be conducted in client’s home or out in the community.
Performs other program related duties as assigned.