Integrated Care Coordinator

Position Title

Integrated Care Coordinator

Health Connect America

Join a dynamic and supportive community where you can make a difference in the lives of others. Apply now to be part of our impactful team at Health Connect America.

Health Connect America delivers trauma‑informed mental and behavioral health services to children, families, and adults across the nation. Our services are guided by a unified approach and evidence‑based practices, offering care in homes, communities, and office settings.

• Engage with individuals through assessment, coordination, health promotion, and transitional care; document assessments and coordinate with the care team.
• Provide comprehensive care management, coordination, health promotion, individual and family support, and referrals to community services.
• Complete the Care Management Comprehensive Assessment within designated time frames 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 document 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.
• When based in a clinic, facilitate on‑site operations: maintain clinic schedule, make reminder calls, take and document client vitals, complete clinic chart documentation, and provide integrated care services to clients within the medication management program.
• Manage Integrated Care and Clinic roster, tracking census against Carelogic.
• Provide health education resources to medication management clients regarding diagnoses and medications recommended by the Nurse Practitioner.

• Minimum of two (2) years of experience working directly with individuals with behavioral health conditions (or specific state qualifications). Additional requirements by state (e.g., TN: Bachelor’s degree in a human services field; NC: Qualified Professional status as defined by NCAC).
• State‑specific licensure or certification (e.g., MH/SU license, RN with required experience, specialty certification). See state regulations for full criteria.
• Experience in case management, community resource coordination, and therapeutic relationships.

• Flexibility in scheduling.
• Employee Assistance Program (EAP) with 8 free counseling sessions annually.
• Paid time off, paid holidays and a comprehensive benefits package (medical, dental, vision, and voluntary insurance).
• Health Navigator support.
• Health Savings Account with company contribution.
• Dependent Daycare Flexible Spending Account.
• Health Reimbursement Account.
• 401(k) retirement plan.
• Benefits Hub.
• Tickets at Work.

Health Connect America and its companies are an Equal Opportunity Employer and consider applicants for employment without regard to race, color, religion, sex, orientation, national origin, age, disability, genetics, or any other basis forbidden under federal, state, or local law.