Care Coordinator at Southern… · Location…

Care Coordinator

Under the supervision of the CCBHC Director and Program Manager, the Care Coordinator plays a central role in delivering integrated, person-centered care coordination services within a Certified Community Behavioral Health Clinic (CCBHC) model. This position combines direct client engagement, population health management, and data-informed care coordination to ensure timely identification, outreach, and intervention for individuals with behavioral health, substance use, and physical health needs across the CCBHC site.

The Care Coordinator collaborates closely with the CCBHC Director, SCHARP Programs, and CQI Analyst to ensure screening for risk, timely access to services, internal and external referrals, age-appropriate physical health screening for all participants, monitor key health indicators and risk factors, and coordinate linkage to primary medical care. The role also supports the accurate, timely, and complete collection of required quality measures data (including SUPRT data), ensuring alignment with CCBHC model of care, CARF accreditation, and SAMHSA quality care and federal reporting requirements.

Position Requirements:

• Bachelor’s degree in Social Work, Psychology, Public Health, Health Administration, or related field (Master’s preferred)
• Experience in behavioral health, integrated care settings, CCBHC, or FQHC settings.
• Experience working with diverse, low-income, and high-acuity populations.
• Proficiency in EHR/EMR systems and documentation standards.
• Valid driver’s license and ability to travel as needed.

Position Competencies:

• Care Coordination & Systems Navigation: Ability to link consumers to behavioral health, medical, and social services efficiently.
• Data-Informed Practice: Uses registries, screenings, and dashboards to guide outreach and follow-up.
• Clinical Awareness: Understanding of behavioral health, SUD, and chronic condition management.
• Communication: Strong interdisciplinary collaboration and client engagement skills.
• Equity & Trauma-Informed Care: Applies culturally responsive and trauma-informed approaches.
• Problem-Solving: Identifies care gaps and implements timely interventions.
• Organization & Prioritization: Manages high caseloads and competing priorities effectively.
• Familiarity with medical terminology and laboratory procedures.
• Excellent oral and written communication, and interpersonal skills.
• Proficient in the use of electronic behavioral health and medical records (EHR) software.
• Bilingual abilities are a plus.
• Must have at least one-year experience working with behavioral health populations including homeless persons with co-occurring disorders.
• Must be experienced working with low income, diverse populations including persons affected by mental illness, substance use and incarceration.

Primary Duties:

• Participate in the walk-in screening protocol, adhere to internal referral workflow processes, and utilize warm hand-off if possible and when appropriate.
• Raise awareness of our CCBHC through community outreach, outreach among care coordination partners, as well as to participate at in-person community events as assigned by CCBHC Director.
• Ensure children and older adults receive age-appropriate screening at respective CCBHC site.
• Provide high-touch care coordination to ensure individuals receive physical health screening and are linked fully to outpatient Primary Care Provider and dental services through the community.
• Ensure collection of complete SUPRT measures for all randomly selected consumers as part of the Crenshaw site sampling population, consistent with CCBHC Criteria 4.G., and that completed measures are delivered in a timely and complete manner to CQI Analyst, CCBHC Director, and Evaluator.
• Complete required training to serve as a Department of Health Care Services (DHCS) Coverage Ambassador.
• Coordinate care across: Behavioral health services; Primary care providers; Substance use treatment (including MAT/OUD services); Housing, DPSS Benefits, and social services.
• Ensure consumers are offered transportation assistance to reduce transportation as a barrier to accessible care.
• Serve as a health navigator and medical chaperone when appropriate and necessary to ensure access to linkages to meet the SDOH, health, and mental health needs of consumers.
• Serve as a liaison between consumers, family members, and various healthcare professionals.
• Educate consumers and their families on health conditions, preventive care, and lifestyle choices.
• Help consumers navigate the healthcare system, including scheduling with specialists, understanding medical bills, and coordinating transportation.
• When needed, accompany consumers to health-related appointments.
• Track and facilitate follow-up appointments, ensuring continuity of care and adherence to treatment plans.
• Monitor individualized care plans.
• Ensure follow-up on referrals and service linkages.
• Utilize dashboards and reports to identify and track:
  • consumers overdue for physical health screenings (annual)
  • consumers requiring 6-month treatment plan updates
  • consumers with elevated PHQ-9 scores needing follow-up
  • consumers screening positive on AUDIT-C
  • Individuals with OUD requiring rapid MAT referral
  • consumers experiencing or at risk of homelessness
• Prioritize outreach based on clinical risk and service gaps.
• Consistent with CCBHC Criteria 4K, works closely with Veterans Care Coordinator to ensure Active Duty Service Members (ADSM) use their servicing Military Treatment Facility, and their MTF Primary Care Managers (PCMs) are contacted by the CCBHC regarding referrals outside the MTF.
• Collaborate with providers, therapists, and case managers to ensure:
  • Timely follow-up on identified needs
  • Same-day or rapid referrals when clinically indicated
  • Continuity of care across services
• Support care transitions (e.g., hospital discharge, intake to ongoing care)
• Identify gaps in care delivery and escalate concerns to leadership.
• Participate in Continuous Quality Improvement (CQI) initiatives.
• Maintain accurate, timely, and complete documentation in the HER.
• Ensure all care coordination activities, outreach attempts, and outcomes are recorded
• Support data accuracy for reporting and audits.
• Work closely with CCBHC Director to coordinate population health and wellness programs for consumers.
• Participate in team meetings, case conferences, and supervision.
• Adhere to workflows related to: Screening tools; Care coordination expectations; Documentation standards.
• Collaborate in a multidisciplinary, team-based care environment.
• Meets with CCBHC Director to achieve program goals & objectives.
• Attends CCBHC weekly care coordination meetings prepared to provide the team status updates and any SDOH barriers on identified individuals.
• Participates in community events as assigned to strengthen outreach, engagement, and community partnerships as part of the CCBHC model of care.
• Other duties and responsibilities as assigned.