Integrated Care Coordinator

HEALTH CONNECT AMERICA, INC•Morristown, TN

About The Position

Health Connect America is seeking an Integrated Care Coordinator to provide comprehensive, person-centered care for individuals and families receiving mental and behavioral health services. The coordinator plans, coordinates, and monitors individualized treatment and care plans aligned with behavioral health goals, closes care gaps, tracks progress, and supports quality and regulatory compliance. The role also includes assisting a Nurse Practitioner with clinic appointment documentation and on-site facilitation when clinic-based, supporting referral marketing, and conducting outreach to integrated care members to explain the program and facilitate enrollment. The coordinator works with individuals, families, providers, treatment teams, and community resources to assess needs, coordinate health promotion and transitional care, facilitate referrals, and support continuity across care settings. Duties include completing comprehensive assessments, monitoring required exams and medication follow-up, maintaining timely and compliant records, monitoring HEDIS gaps and enrollment status, and developing individualized plans that address unmet health needs and Social Determinants of Health. Crisis response and on-call support may also be required. For clinic-based positions, the coordinator facilitates clinic operations, maintains schedules and rosters, conducts reminder calls, takes and documents client vitals, completes chart documentation, provides integrated care services, and shares health education resources with medication-management clients about diagnoses and medications provided by the Nurse Practitioner. Qualifications vary by state. Tennessee requires a bachelor’s degree in any discipline, with a preference for human services or a related field, and experience working with children and families in case management or community-resource work. North Carolina applicants must meet at least one stated Qualified Professional qualification, and additional behavioral-health or LTSS experience requirements apply depending on the population served.

Requirements

Tennessee: Bachelor’s degree in any discipline.
Tennessee: Experience working with children and families in case management-type or community-resource positions.
North Carolina: Meet at least one of the listed Qualified Professional qualifications: an MH/SU license (including associate-level) or NC Substance Abuse Board certification; an RN and four years of full-time MH/SU/IDD population experience; a master’s degree in a human-service field and at least one year of such full-time experience; a bachelor’s degree in a human-service field and at least two years of such full-time experience; or a bachelor’s degree in a non-human-service field and at least four years of such full-time experience.
North Carolina: For care managers serving members with behavioral-health needs, two years of experience working directly with individuals with behavioral-health conditions.
North Carolina: For 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 qualification and experience requirements. This experience may be concurrent with the specified two years of behavioral-health, I/DD, or TBI experience.
Meet the requirements of a comprehensive background investigation before joining the organization.

Nice To Haves

Tennessee: A degree in human services or a related field is preferred.

Responsibilities

Engage individuals through assessment, coordination, health promotion, and transitional care; document assessments and coordinate with care and treatment teams.
Provide care management, coordination, health promotion, individual and family supports, and referrals to community services.
Complete the Care Management Comprehensive Assessment within designated timeframes and share results with primary care providers and relevant agencies.
Ensure clients receive required physical exams, medication monitoring, and appropriate services.
Maintain medical-record compliance and timely documentation of care-coordination activities.
Monitor HEDIS gaps and verify client payer and program enrollment status monthly.
Develop individualized, person-centered care plans based on assessment results and Division guidelines, addressing unmet health needs and Social Determinants of Health.
Coordinate follow-up after hospitalizations and life transitions to support smooth transitions of care.
Identify and provide crisis response as needed, participate in post-crisis debriefing, and provide on-call support.
Communicate with individuals, providers, and natural supports and educate them about services.
Build collaborative relationships with care-team members and community resources, improve resource linkage, and document follow-up.
Support transitions between care settings and develop discharge or transition plans.
Attend treatment-team, supervision, and integrated-care-team meetings and serve as a liaison with professionals and agencies.
Assist with marketing new client referrals and provide on-call support as needed.
Review data for service appropriateness and compliance issues.
Attend training and comply with agency policies, procedures, and state regulatory requirements.
When clinic-based, facilitate clinic operations, maintain the office clinic schedule, make reminder calls, take and document client vitals, complete clinic chart documentation, and provide integrated care services to clinic clients, particularly integrated-care clients in the medication-management program.
Manage the office Integrated Care and Clinic Roster and track clinic census so it matches the census in Carelogic.
Provide medication-management clients with health education resources regarding diagnoses and medications provided by the Nurse Practitioner.

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, dental, and vision insurance, plus other voluntary insurance products.
Access to a Health Navigator.
Health Savings Account with company contribution.
Dependent Daycare Flexible Spending Account.
401(k) retirement plan.
Benefits Hub.
Tickets at Work.