Behavioral Health Integrated Care Coordinator-Adult

Job Summary:

The Behavioral Health Integration Coordinator
- Adult or Child- will manage a dynamic case load and serve as a hub for the collaborative delivery within the larger behavioral health home team. The Behavioral Health Integration Coordinator will be a link for patients, supporting their on-going goals and objectives. Integration Coordinators will ensure patients have access to an array of community resources, including support with food insecurity, housing, as well as gaps in care.

They will work closely with patients in the community, offering a variety of virtual, in-office, and in-home locations for care delivery, ensuring that all aspects of physical and mental health needs are assessed and addressed.

• Supports and promotes the mission and values of Covenant Health Ministry.
• Treats patients and colleagues with dignity and respect, applying a strengths-based, trauma informed approach to care.
• Works with the behavioral health home team to involve other support services (ie, peer support, nurse navigation) with permission.
• Helps to ensure a seamless transition of care by helping arrange and /or scheduling appointments. May also attend community appointments, if needed.
• Supports and educates patients regarding transitional supports as well as community resources, helping remove access barriers to medical, dental, housing resources, or other needs as identified.
• Collaborates and communicates with other care team members, (ie PCP, Psychiatry, etc)
• Assist patients with Medicaid requirements and coverage renewals.
• Contacts community resources routinely to establish availability and referral capacity.
• Communicates professionally with referral sources and returns phone calls promptly.
• Collect patient’s medical and behavioral history to the complete referrals requested, following HIPPA guidelines and system policies.
• Attends patient appointments with medical and behavioral clinicians as needed.
• Documents an individualized plan and safety plan for each patient, reflecting their voice and central role in any care provided.
• Documents progress towards the plan objectives as well as collateral contacts.
• Manages a dynamic case load ensuring that patients are actively participating in care.
• Communicates regularly with clinical lead/program manager regarding individual patient progress or treatment issues.
• Attends and participates in individual and team meetings with clinical lead. Informs clinical lead of any conflicts of interest, client crises, or other situations that require further review/ assessment.
• Demonstrates ability to be open and willing to receive constructive feedback regarding client care.
• Attends and actively engages in program meetings.
• If needed, helps to follows up after a missed appointment.
• Maintains all required competencies and completes annual compliance courses on time.
• Participates in community outreach activities.
• Other duties as consistent with this role
• BHH only - Completes all needed authorizations and reviews in Acentra. Tracks required due dates to enable monthly attestation and authorization compliance. Documents in EPIC to standards outlined in Mainecare Section 92, State of Maine Mental Health Licensing, and Covenant Health System Policies.
• Child Coordinators only - will support families regarding transitional supports as well as community, helping remove access barriers to medical, dental, food-SNAP, childcare or other needs as identified.
• Works with the unit teacher, social worker and school systems to help patients with re-entry attending IEP/ 504 plans as needed.
• Strong Futures Only - will work with Inpatient Care Team and family to assess patient needs at discharge, working collaboratively to identify gaps in recommended services.…