Care Coordinator

TITLE:  CARE COORDINATOR

REPORTS TO:  HOME-BASED SERVICES SUPERVISOR

STATUS:  EXEMPT

MAIN FUNCTION:  The Care Coordinator supports clients by facilitating access to behavioral health, medical, and social services. This position coordinates care across multiple providers and systems to ensure clients receive comprehensive, person-centered services that promote recovery and well-being. The Care Coordinator collaborates closely with clients, families, and the multidisciplinary team to assist in implementing and monitoring individualized care plans.

DUTIES/RESPONSIBILITIES:

• Provide all services in accordance with the policies and procedures of Heartland Counseling Services, applicable professional codes of ethics, and all payor, licensing, and governmental rules.


• Conduct and Review comprehensive Needs Assessment to identify client needs, strengths, and barriers while considering provider recommendations.


• Implement, and monitor individualized care plans in collaboration with clients, families, and clinical teams.


• Facilitate timely access to behavioral health, physical health, social, and community resources.


• Coordinate referrals and follow-up with internal and external providers to ensure continuity of care.


• Coordination during transitions in levels of care.


• Document client services provided according to clinical standards, rules, regulations, and agency procedures.


• Participate in interdisciplinary team meetings, care coordination meetings, and quality improvement initiatives.


• Assist clients with appointment scheduling, transportation, and other logistical needs.


• Advocate for clients to reduce barriers to care, including addressing social determinants of health.


• Maintain confidentiality and professional boundaries at all times.


• Collaborate with providers such as primary care physicians, therapists, nurses, and peer support specialists.


• Assist with the collection, maintenance, and analysis of participant data as needed.


• Ensure compliance with all required regulations and standards.


• Perform other related duties as assigned.

REQUIRED SKILLS/ABILITIES:

• Maintains confidentiality when working with clients.


• Strong verbal and written communication skills.


• Ability to work effectively in a multidisciplinary team environment.


• Knowledge of behavioral health, substance use, and social service systems.


• Skilled in problem-solving and client advocacy.


• Proficient in electronic health records (EHR) documentation.


• Ability to develop positive relationships with diverse populations.


• Strong organizational and time management skills.


• Possess a valid driver’s license and an insurable driving record (if applicable).

EDUCATION & EXPERIENCE:

• Bachelor’s degree in social work, psychology, nursing, counseling, or related field preferred.


• Minimum 2 years of experience in behavioral health, case management, or care coordination. Experience in a CCBHC or community mental health setting preferred.

PHYSICAL REQUIREMENTS:

• Prolonged periods of sitting at a desk and working on a computer.


• Must be able to lift up to 15 pounds at times.