IHH Care Coordinator / BHC - ACCESS Sinai

ACHN • Chicago, IL

6d

About The Position

The Behavioral Health Consultant (BHC) is a .60 FTE member of a multidisciplinary primary health care team who provides behavioral health consultation and treatment to children, adolescents, and adults to improve psychosocial functioning and overall health outcomes. The Integrated Health Home (IHH) Program Care Coordinator is a Licensed Social Worker at .40 FTE who provides care coordination, education, social support, and outreach to help patients navigate health care transitions and strengthen patient empowerment through health education, advocacy, and coaching.

The position requires proven experience with Serious Mental Illness (SMI) and applies a Triple Aim approach: improving the patient experience, improving population health, and lowering health care costs. The role primarily serves patients with SMI. It oversees intake and care plans, supports transitions across care settings, connects patients and families with resources, and provides behavioral health assessment and brief interventions as part of an integrated care model.

The work takes place regularly in a normal office environment and occasionally in a health center. Local travel between clinical and health centers, hospitals, and community sites is required. For remote or hybrid work, a secure work environment and reliable high-speed internet are required. The role involves computer work for up to four hours and lifting up to 10 pounds.

Requirements

• Master’s degree.
• Current unrestricted Illinois licensure as an LCPC, LCSW, or LMFT.
• Three to five years of experience in a clinical setting.
• Proven experience with Serious Mental Illness (SMI).
• Excellent working knowledge of evidence-based mental health and behavioral interventions.
• Valid driver’s license and proof of insurance when using a personal vehicle.
• For remote or hybrid work, a secure remote work environment and reliable high-speed internet connection.

Nice To Haves

• Previous care coordination experience.
• Proficiency with Electronic Health Records (EHR) and EPIC.
• Intermediate proficiency in Microsoft Office Suite, including Word, Excel, and PowerPoint.

Responsibilities

• Oversee the intake process, maintain care plans, and promote health programs and services.
• Use information systems to contact, educate, engage, and track patients based on disease risk, self-management, and family or community needs.
• Assist patients and providers with transitions between outpatient and inpatient settings and ensure follow-up after emergencies, hospitalizations, and specialist visits.
• Provide resources that support patient and family self-management, assess readiness to learn, and validate learning outcomes.
• Engage patients and families in care decisions, encourage questions and concerns, and recognize their expertise through coaching and counseling.
• Conduct screenings, assessments, and diagnoses of mental health conditions while identifying barriers to optimal physical health.
• Assess crises and implement appropriate interventions to support patient well-being.
• Identify at-risk patients and develop plans to prevent further psychological or physical deterioration.
• Deliver brief, focused interventions for mental and behavioral health concerns.
• Participate in meetings that support the integrated healthcare model and comprehensive patient care.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time