Integrated Care Coordinator

Health Connect America•Jackson, TN

About The Position

Join Our Impactful Team at Health Connect America! Before you get started on your journey with Health Connect America , take some time to learn more about us. At Health Connect America , all services are guided by a unified, trauma-informed approach. Across every program, we are committed to providing compassionate, client-centered care that fosters healing and growth. Our services are delivered by clinically trained staff, grounded in a therapeutic mindset and informed by research and evidence-based practices at every level of care. Health Connect America and its affiliate brands are leaders in providing mental and behavioral health services to children, families, and adults across the nation. We provide our services directly to those in need whether that be within a person's home, their community, or in one of our office settings. Health Connect America is honored to be a part of the communities we serve and the clients we walk alongside as they embark on a journey to self-improvement and more fulfilling lives. At Health Connect America , we are dedicated to making meaningful connections every day through creating quality, affordable opportunities for individuals and families to achieve their greatest potential in a safe, positive living environment. Come make a difference and grow with us! Our Brands Responsibilities The primary responsibilities of the Integrated Care Coordinator are to deliver comprehensive, person-centered care by planning, coordinating, and monitoring individualized treatment plans to align with behavioral health goals. They play a pivotal role in closing gaps, tracking progress, and upholding the highest standards of quality and regulatory compliance. Assist the Nurse Practitioner with clinic appointment related documentation and facilitation on site when working in the clinic. Additionally, they support marketing initiatives for new referrals and engage in outreach to integrated care attributed members, providing education on our program, and facilitating enrollment. Actively engage with individuals through assessment, coordination, health promotion, and transitional care, documenting assessments and coordinating with the care team and treatment teams. Provide comprehensive 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 ensure timely documentation of care coordination activities. Monitor HEDIS gaps and verify client payer and program enrollment status monthly. Develop individualized, person-centered care plans incorporating assessment results and Division’s guidelines, focusing on unmet health needs and Social Determinants of Health (SDOH). Coordinate follow-up services for recent hospitalizations or life transitions, ensuring smooth transitions of care. Identify and provide crisis response as necessary, participate in post-crisis debriefing, and be available for on-call support. Communicate effectively with individuals, providers, and natural supports, providing education on services. Establish collaborative relationships with care team members and community resources to improve resource linkage and documenting follow-up. Support transitions between care settings and develop comprehensive discharge or transition plans. Attend Treatment Team and supervision meetings, integrated care team meetings, and serve as a liaison with other 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 sessions and comply with agency policies and procedures. Ensure compliance with all state regulatory requirements. Responsible to the following when based in a clinic: Facilitate on-site clinic operations including but not limited to maintaining office clinic schedule, complete clinic reminder calls, taking and documenting client vitals, completing clinic chart documentation, and integrated care services for all clinic clients, especially integrated care clients only in med management program. Manage and maintain Integrated Care and Clinic Roster for the office including tracking and management of clinic census that matches census in Carelogic. Provide health education resources to med management clients regarding diagnoses and medications given by Nurse Practitioner.

Requirements

Qualifications may vary by state due to differing regulations and standards in mental and behavioral health services.
TN: A Bachelor’s Degree in any discipline is required, with a preference for degrees in human services or related fields essential for careers in mental and behavioral health.
Experience working with children and families in case management type/ community resource position.
NC: Minimum of one of the following qualifications to meet criteria as a Qualified Professional (QP). Per 10A NCAC 27 .0104 a MH/SU license (including associate-level), or are certified by the NC Substance Abuse Board or, a RN AND have four years of full-time experience working with the MH/SU/IDD population or, a master’s degree in a human service field AND at least one year of full-time experience working with the MH/SU/IDD population or, a bachelor’s degree in a human service field AND at least two years of full-time experience working with the MH/SU/IDD population or, a bachelor’s degree in a non-human service field AND at least four years of full-time experience working with the MH/SU/IDD population.
Two years of experience working directly with individuals with behavioral health conditions (if serving members with behavioral health needs).
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 required cited above. (This experience may be concurrent with the two years of experience working directly with individuals with behavioral health conditions, an I/DD, or a TBI, above.)

Responsibilities

Deliver comprehensive, person-centered care by planning, coordinating, and monitoring individualized treatment plans to align with behavioral health goals.
Assist the Nurse Practitioner with clinic appointment related documentation and facilitation on site when working in the clinic.
Support marketing initiatives for new referrals and engage in outreach to integrated care attributed members, providing education on our program, and facilitating enrollment.
Actively engage with individuals through assessment, coordination, health promotion, and transitional care, documenting assessments and coordinating with the care team and treatment teams.
Provide comprehensive 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 ensure timely documentation of care coordination activities.
Monitor HEDIS gaps and verify client payer and program enrollment status monthly.
Develop individualized, person-centered care plans incorporating assessment results and Division’s guidelines, focusing on unmet health needs and Social Determinants of Health (SDOH).
Coordinate follow-up services for recent hospitalizations or life transitions, ensuring smooth transitions of care.
Identify and provide crisis response as necessary, participate in post-crisis debriefing, and be available for on-call support.
Communicate effectively with individuals, providers, and natural supports, providing education on services.
Establish collaborative relationships with care team members and community resources to improve resource linkage and documenting follow-up.
Support transitions between care settings and develop comprehensive discharge or transition plans.
Attend Treatment Team and supervision meetings, integrated care team meetings, and serve as a liaison with other 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 sessions and comply with agency policies and procedures.
Ensure compliance with all state regulatory requirements.
Facilitate on-site clinic operations including but not limited to maintaining office clinic schedule, complete clinic reminder calls, taking and documenting client vitals, completing clinic chart documentation, and integrated care services for all clinic clients, especially integrated care clients only in med management program.
Manage and maintain Integrated Care and Clinic Roster for the office including tracking and management of clinic census that matches census in Carelogic.
Provide health education resources to med management clients regarding diagnoses and medications given by Nurse Practitioner.

Benefits

We offer flexibility in scheduling and provide all employees access to our Employee Assistance Program (EAP), which includes 8 mental health counseling sessions annually.
Full-time HCA employees enjoy paid time off, paid holidays, and a comprehensive benefits package that includes medical, dental, vision, and other voluntary insurance products.
Additional benefits include:
Access to a Health Navigator
Health Savings Account with company contribution
Dependent Daycare Flexible Spending Account
Health Reimbursement Account
401(k) Retirement Plan
Benefits Hub
Tickets at Work