Integrated Care Coordinator

Health Connect America•Morristown, TN

About The Position

The Integrated Care Coordinator delivers comprehensive, person-centered care by planning, coordinating, and monitoring individualized treatment plans aligned with behavioral health goals. The role helps close care gaps, track progress, and maintain quality and regulatory compliance. It supports Nurse Practitioner clinic appointments through documentation and on-site facilitation when working in a clinic, and helps market services to new referrals, reach integrated care attributed members, explain the program, and facilitate enrollment. The coordinator engages individuals through assessment, care coordination, health promotion, and transitional care, documenting assessments and coordinating with care and treatment teams. The role includes comprehensive care management, individual and family support, referrals to community services, monitoring of health needs and care-plan progress, follow-up after hospitalizations or life transitions, and crisis response as necessary. The coordinator also collaborates with providers, natural supports, community resources, and other professionals and agencies. For clinic-based work, the coordinator helps facilitate clinic operations, including managing schedules and reminder calls, taking and documenting client vitals, completing clinic chart documentation, and providing integrated care services to clinic clients, particularly integrated care clients in the medication management program. The position also maintains the office’s Integrated Care and Clinic Roster and provides health education resources to medication management clients about diagnoses and medications given by the Nurse Practitioner.

Requirements

For Tennessee: Bachelor’s degree in any discipline; experience working with children and families in case management-type or community resource positions.
For Tennessee: A degree in human services or a related field is preferred.
For North Carolina: Meet at least one Qualified Professional qualification: an MH/SU license, including associate-level; certification by the NC Substance Abuse Board; RN plus four years of full-time experience working with the MH/SU/IDD population; master’s degree in a human service field plus at least one year of full-time experience with that population; bachelor’s degree in a human service field plus at least two years of full-time experience with that population; or bachelor’s degree in a non-human service field plus at least four years of full-time experience with that population.
For North Carolina, care managers serving members with behavioral health needs: two years of experience working directly with individuals with behavioral health conditions.
For North Carolina, care managers serving members with LTSS needs: two years of prior LTSS and/or HCBS coordination, care delivery monitoring, and care management experience, in addition to the applicable qualifications above. This experience may be concurrent with the specified experience working with individuals with behavioral health conditions, an I/DD, or a TBI.
Qualifications may vary by state due to differing regulations and standards in mental and behavioral health services.

Nice To Haves

For Tennessee, a degree in human services or a related field is preferred.

Responsibilities

Plan, coordinate, and monitor individualized, person-centered treatment and care plans aligned with behavioral health goals and Division guidelines, addressing unmet health needs and Social Determinants of Health.
Engage individuals through assessment, care coordination, health promotion, and transitional care; document assessments and coordinate with care and treatment teams.
Complete the Care Management Comprehensive Assessment within designated timeframes and share results with primary care providers and relevant agencies.
Provide comprehensive care management, individual and family supports, health promotion, and referrals to community services.
Ensure clients receive required physical exams, medication monitoring, and appropriate services.
Maintain medical record compliance and document care coordination activities in a timely manner.
Monitor HEDIS gaps and verify client payer and program enrollment status monthly.
Coordinate follow-up services after hospitalizations or life transitions, support transitions between care settings, and develop comprehensive discharge or transition plans.
Identify and provide crisis response as necessary, participate in post-crisis debriefing, and provide on-call support as needed.
Communicate with individuals, providers, and natural supports, and provide education on services.
Build collaborative relationships with care team members and community resources to improve resource linkage and document follow-up.
Attend Treatment Team, supervision, and integrated care team meetings; serve as a liaison with professionals and agencies.
Support marketing initiatives for new referrals, conduct outreach to integrated care attributed members, explain the program, and facilitate enrollment.
Review data for service appropriateness and compliance issues; attend training and comply with agency policies, procedures, and state regulatory requirements.
When clinic-based, facilitate on-site clinic operations, including maintaining the clinic schedule, making reminder calls, taking and documenting client vitals, completing clinic chart documentation, and providing integrated care services to clinic clients, especially integrated care clients in the medication management program.
Maintain the office Integrated Care and Clinic Roster and track clinic census to match the census in Carelogic.
Provide medication management clients with health education resources about diagnoses and medications given by the Nurse Practitioner.
Assist the Nurse Practitioner with clinic appointment documentation and on-site facilitation when working in the clinic.

Benefits

Flexible scheduling
Employee Assistance Program, including eight mental health counseling sessions annually
Paid time off for full-time employees
Paid holidays for full-time employees
Medical insurance
Dental insurance
Vision insurance
Other voluntary insurance products
Health Navigator access
Health Savings Account with company contribution
Dependent Daycare Flexible Spending Account
401(k) Retirement Plan
Benefits Hub
Tickets at Work