Care Coordinator, CCBHC

The Care Coordinator, CCBHC'S (Certified Community Behavioral Health Clinic), in collaboration with the CCBHC Outpatient team, is responsible for coordinating referrals and linkages to help members navigate and access services. The Care Coordinator's role supports members through community outreach and case management to improve health and recovery outcomes. Furthermore, this role is responsible for maintaining the quality of data tracking and reporting in alignment with CCBHC requirements.

• Monitors and facilitates access, engagement and linkage to healthcare services and resources for Thresholds CCBHC members.
• Provides case management by phone and in person to refer and link members to external healthcare providers and community resources to facilitate and improve continuity of care, promote progress toward recovery goals, and address social determinants of health. Depending on the member's case management needs, activities could include a wide range of things like helping someone apply for Medicaid, follow-up with Social Security, enroll for classes, apply for affordable housing, find food pantries, learn to ride public transportation, learn ways to track appointments, find activities to do in line with the member's interests and values, find out where to go for things like tax filing, affordable child care, and legal support, and other similar things necessary for a member's success.
• Provides community outreach to members to assist with linkage to mental health, physical health, substance use services and other resources.
• Follows up with collateral providers to facilitate improved continuity of care.
• Reaches out to members who miss appointments to address barriers to care.
• Identifies gaps in care for members and arranges appropriate and timely resolution, providing support to remove common obstacles and barriers to outpatient care and resources.
• Attends and participates in team and branch meetings.
• Documents member care and related communication in the electronic health record in accordance with state, federal, and Thresholds requirements.
• Establishes and oversees a process for communicating pertinent member information and status reports to designated Thresholds and community healthcare providers.
• Advocates for members who may be vulnerable or need additional support.
• Creates and develops relationships with community providers to find resources for our members by attending networking meetings, visiting or contacting agencies, and attending information fairs.
• Participates in regularly scheduled caseload consultation. These consultations may focus on members who are new to treatment, difficult to engage, or who are not improving as expected.
• Identifies and links members to Thresholds Supported Employment IPS program and assists members with applications for financial and/or medical benefits.
• Completes the NOMS (National Outcome Measures) and submits them in a timely manner.

MARGINAL DUTIES & RESPONSIBILITIES

• May be required to work flexible schedules and be available to work on weekends or evenings as
  required.

EDUCATION

• Must, at a minimum, have a high school diploma and at least two (2) years of mental health and/or community engagement experience.
• Mental Health Professional designation (meeting Office of Mental Health Rule 132 credential requirements) is strongly preferred.
  
  
  
  • High school diploma or GED certificate and 5 years of supervised clinical experience
  • Bachelor's degree in Psychology, Social Work, or related field
  • Bachelor's degree in an unrelated field and 2 years of supervised clinical experience
  
  
  
  
• Qualified Mental Health Professional including a Master's degree in social work, counseling, or closely related field is a plus.

EXPERIENCE

• Experience working with persons diagnosed with mental illness preferred.
• Experience engaging with the community to promote services is a plus.
• Ability to document services provided in an Electronic Health Record in a timely manner.
• Daily access to a personal vehicle is required. Must obtain and maintain $100,000/$300,000/$100,000 bodily injury and liability insurance. Subject to validation every six months.
• May be required to provide transportation for members of the program using a Thresholds provided vehicle or personal vehicle. Must be 23 years of age and must meet all insurance carrier's requirements. Subject to annual Department of Motor Vehicles license verification.

SKILLS/CERTIFICATIONS

• Current and valid driver's license required.