Integrated Care Coordinator, CoCM – Care Management and Behavioral Health

Essen Medical Associates•Bronx, NY

1d•Onsite

About The Position

The Integrated Care Coordinator, CoCM – Care Management and Behavioral Health is a care management and coordination role bridging care management agency services and Collaborative Care Model (CoCM) behavioral health programs. You will carry a caseload from care management agency members requiring care planning, coordination, and both remote and in-person support; and CoCM patients requiring screening, brief evidence-based interventions, registry management, and close collaboration with the Psychiatric Consultant and primary care provider. This role is ideal for a motivated individual — including new graduates — who is passionate about serving underserved, multicultural communities within a high-impact, team-based integrated care environment. We actively welcome and support candidates early in their careers who bring energy, commitment, and a strong foundation in human services or social work.

Requirements

Bachelor's degree required in Social Work, Human Services, Psychology, or a related behavioral health or social sciences field.
Minimum 1 year of experience in a behavioral health setting (e.g., outpatient mental health, substance use, crisis services, community health); OR Minimum 2 years of experience in case management, care coordination, or human services, with meaningful exposure to behavioral health populations.
New graduates with relevant field placement, internship, or practicum experience in behavioral health or care management are strongly encouraged to apply.
Strong communication, engagement, and organizational skills; ability to build rapport with patients in a care coordination relationship.
Proficiency with EHR systems and patient registries; strong documentation skills for billing and compliance.
Reliable transportation required for in-person patient visits.
Commitment to Essen Health Care's mission of serving vulnerable and underserved communities.

Nice To Haves

Master’s degree in social work or related field is a plus but not required.
Familiarity with validated screening tools (PHQ-9, GAD-7) and evidence-based approaches (motivational interviewing, behavioral activation) is a plus.
Experience working with underserved, multicultural, or Medicaid-insured populations highly desirable.
Bilingual English/Spanish strongly preferred.

Responsibilities

Conduct intakes and develop individualized, person-centered care plans for care management agency members.
Screen and assess for common behavioral health conditions using PHQ-9, GAD-7, and other validated tools to guide care planning and appropriate triage.
Provide brief evidence-based interventions including behavioral activation, motivational interviewing, and problem-solving techniques.
Support monitoring of treatment plan progress, including documentation of adherence, changes in symptoms, and coordination with clinical supervisors.
Provide culturally responsive, trauma-informed support reflecting the diversity of communities served.
Serve as the primary point of contact for patients on both care management and CoCM caseloads.
Conduct telephonic and in-person outreach, follow-up, and engagement; conduct in-person visits as required (home, office, or community-based).
Schedule appointments with PCPs, Psychiatric Consultants, and external specialists or community providers.
Identify and address social determinants of health — connect patients with housing, food, transportation, benefits enrollment, and community resources.
Facilitate referrals for clinically indicated services outside the organization (vocational rehabilitation, substance use treatment, social services).
Maintain the CoCM patient registry — tracking enrollment, PHQ-9/GAD-7 scores, treatment milestones, and follow-up status.
Prepare patient summaries for weekly Systematic Case Review (SCR) with the Psychiatric Consultant.
Document all patient interactions accurately and timely in the EHR per care management agency and CoCM billing and regulatory requirements.
Participate in team huddles, case reviews, and quality improvement meetings within your assigned care team.