Clinical Coordination Specialist- Primary Care
About The Position
The Clinical Coordination Specialist plays a pivotal role in facilitating comprehensive client care across services received by ITBC clients, including mental health, addiction medicine, physical healthcare, and community-based services. This position involves creating notifications for physical and behavioral hospitalizations, coordinating emergency room (ER) visits, and managing follow-up appointments after discharge. The Clinical Coordination Specialist manages referrals between services as needed, ensuring seamless transitions for clients across all healthcare services. They engage in Integrated Team-Based Care panel population management and outreach for the client population, contributing to the work of several multi-disciplinary teams in collaboration with Integrated Team-Based Care leadership, and analyzing and bridging the gaps that may exist in systems of care.
Requirements
- BA in a related field (e.g., social or behavioral science, public health) or certification as a QMHA or CADC is preferred but not required.
- At least one year of experience working in a healthcare setting.
- Consumer/customer service experience is required.
- Ability to commute to other locations.
- Ability to perform CPR, First Aid, and effectively use AED equipment.
- BLS/ First Aid certifications are required and must remain current.
Nice To Haves
- Experience in behavioral health and panel management is strongly preferred.
- Understanding of recovery model, motivational interviewing, illness management and recovery, evidence-based practices, and strength-based case management philosophies and strategies.
- Understand and align with harm reduction philosophies, cultural responsiveness, and trauma informed care.
- Knowledge of panel management best practices.
Responsibilities
- Organize and analyze data from client panels to track healthcare utilization and needs, conducting outreach as necessary, tracking quality clinical metrics.
- Coordinate referrals with other client providers in a timely and professional manner, utilizing electronic health records and collaborating with payer support.
- Identify and engage clients in various healthcare services (mental, physical, oral).
- Monitor emergency department (ED) admissions and follow up with clients and the appropriate interdisciplinary team post-discharge.
- Serve on rotation to monitor after-hours/on-call reports for all ITBC clients and crisis services provided for assigned panel members.
- Assist with scheduling external appointments; coordinate with team administrator to ensure clients receive appointment reminders.
- In collaboration with team administrator, coordinate medical equipment orders and transportation for clients.
- Attend all scheduled team huddles, staff meetings, supervision sessions, and departmental meetings to stay informed and engaged with team objectives.
- Collaborate with interdisciplinary teams and community services to address clients’ needs in diabetes management, mental health, preventative health, and health promotion.
- Work closely with the Integrated Team-Based Care leadership and the Population Health team to identify target client populations and develop outreach strategies.
- Attend team meetings focused on health integration and collaborate with project leads to implement plans.
- Adhere to all compliance requirements, including mandatory reporting laws and HIPAA regulations.
- Ensure that all documentation is accurate and maintained in accordance with agency policies and local, state, and federal regulations through the Electronic Health Record System (EHR).
- Complete all annual employee training requirements to ensure ethical practices and professional development, maintaining compliance with organizational standards.
Benefits
- Generous Paid Time Off Package - Full-time employees earn 6 weeks of PTO in their first year!
- Medical and Dental Coverage (begins 1st of the month following hire date)
- VSP Vision Discount Plan
- 403(b) Retirement Plan - Eligible after 60 days with immediate 100% vesting and a 1-to-1 company match up to 3% per pay period, plus the opportunity for an additional discretionary contribution (up to 5%) at the end of the fiscal year .
- Flexible Spending Account (FSA) (Medical, dependent care, and transportation options)
- Short-Term Disability, Long-Term Disability, and Life Insurance
- Paid Bereavement and Jury Duty Leave
- Length of Service Award
- Voluntary Life Insurance
- Supplemental Insurance
- Student loan forgiveness options
- Wellness Benefits: Employee Assistance Program (EAP)
- Bike to Work Reimbursement
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
