Behavioral Health Care Coordinator

Position summary

The Behavioral Health Care Coordinator (BHCC) is responsible for coordinating team-based care for adults with substance use disorders across inpatient and community-based settings. The BHCC will provide clinical support and transitional care management for patients in state funded and commercially insured programs. This role facilitates a shared-goal model between patients, caregivers, physicians, nurse practitioners, therapists, and community resources to ensure safe continuity of care and reduce readmissions/relapses.

• Coordinate enrollment, financial verification, compliance and provide clinical support for patients enrolled in state funded programs.
• Identify eligible transitional care management (TCM) patients from partner programs; verify TCM criteria and initiate the TCM episode in the electronic health record.
• Complete direct telephonic/electronic outreach to patients/caregivers within 2 business days of discharge to review discharge instructions, reconcile medications, screen for risk, and schedule the TCM visit.
• Coordinate and schedule face‑to‑face TCM visits with physicians/nurse practitioners within required time frames (7 or 14 days) based on clinical need and anticipated medical complexity.
• Collect and organize discharge summaries, medication lists, and after‑care plans; reconcile information and prepare succinct handoffs for clinicians.
• Develop and maintain patient‑centered care plans addressing substance use disorder, co‑occurring mental health conditions, medication‑assisted treatment, and psychosocial needs, in collaboration with the care team.
• Arrange referrals and services including intensive outpatient/outpatient therapy, psychiatry, peer support, sober housing, and community resources; monitor engagement and barriers.
• Conduct structured follow‑up calls/portal messages during the 30‑day TCM period to monitor symptoms, adherence, relapse risk, and social determinants; elevate clinical concerns promptly to physicians/nurse practitioners.
• Track and document all non‑face‑to‑face coordination and management activities by clinical staff under physician/nurse practitioner direction for TCM billing support.
• Collaborate with billing/coding and revenue cycle teams to ensure accurate charge capture, respond to payer requests, and assist with denial resolution.
• Participate in quality improvement initiatives related to readmission reduction, overdose prevention, engagement in medication‑assisted treatment, and TCM performance metrics.
• Manage ~12 patient case load for state treatment services grant. Basic duties include:
• Monthly outreach calls to program participants
• Resource navigation and coordination
• Collaboration with program clinicians
• Program enrollment and compliance with mandated clinical and financial eligibility assessments

• Education: Preferred:
  Bachelor’s degree (ideally in nursing, social work, psychology, or related health field); LCDC, LMSW, Behavioral health nursing or equivalent clinical degree.
• Experience: 2+ years of experience in behavioral health, community health agency, or integrated primary care practice, with direct care coordination or case management responsibilities.
• Prior experience with hospital or residential discharge planning and/or transitional care management, chronic care management, or case management programs preferred.
• Skills:
• Strong working knowledge of substance use disorder, co‑occurring mental health conditions, medication‑assisted treatment, and community recovery resources.
• Familiarity with TCM requirements and clinical coding documentation standards, or willingness to obtain training.
• Excellent communication skills, motivational interviewing or similar engagement techniques, and comfort working with high‑acuity, high‑risk populations.
• Proficiency with electronic health records, registries, and care‑management tools; ability to multitask and prioritize in a fast‑paced outpatient setting.

• Outpatient behavioral health/addiction medicine clinic with close collaboration with hospitals, detox/residential programs, and community agencies.
• Primarily weekday, daytime hours with occasional early/late calls to meet 2‑business‑day outreach requirements.

Pay: $50,000.00 - $60,000.00 per year

• 401(k)
• Health insurance
• Life insurance
• Paid time off
• Vision insurance