Care Coordinator - OPBH & Vitality

Care Coordinator - OPBH & Vitality for Life - Full Time

The Care Coordinator provides comprehensive care management services to patients receiving treatment through the Outpatient Behavioral Health Clinic. The position focuses on improving patient outcomes through assessment, care coordination, resource management, patient advocacy, interdisciplinary collaboration, and community partnership development. The Care Coordinator serves as a central point of contact for patients with complex behavioral health, medical, and psychosocial needs and works to reduce barriers to treatment, improve engagement in care, and promote recovery-oriented outcomes.

• Bachelor’s degree in a mental health or related field required (e.g. Counseling, Social Work, Psychology, etc.)
• Master’s degree in mental health field preferred (e.g. Counseling, Social Work, Marriage and Family).
• Community Health Worker preferred.
• Licensed Master Social Worker preferred.
• Non-Violent Crisis Intervention (within 90 days of hire).

• Minimum two (2) years of experience within behavioral health, healthcare, care management, or related field.
• Demonstrated skills in the areas of de-escalation, negotiation, communication (verbal and written), conflict resolution, interdisciplinary collaboration, care/case management, creative problem solving, and critical thinking.
• Knowledge of outpatient and inpatient behavioral health services, including community and organizational resources, and patient care process.
• Basic knowledge of quality improvement, insurance verification and utilization management as it relates to third-party payers.
• Excellent verbal and written communication skills required.
• Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
• Intermediate computer skills required.

• Conduct comprehensive biopsychosocial assessments to identify patient strengths, needs, risks, and barriers to care.
• Develop, implement, monitor, and update individualized care management plans in collaboration with patients, families, and treatment team members.
• Identify high-risk, high-utilization, and medically complex behavioral health patients who may benefit from enhanced care management services.
• Coordinate transitions of care between outpatient, inpatient, emergency department, primary care, specialty care, and community-based services.
• Monitor patient progress toward treatment goals and intervene when barriers to care or treatment adherence are identified.
• Support patients in achieving improved health outcomes, increased functioning, and enhanced quality of life.
• Utilize evidence-based and recovery-oriented approaches to support patient engagement and self-management.
• Maintain accurate and timely documentation in the electronic health record in accordance with organizational, regulatory, and payer requirements.

• Provide supportive interventions, psychoeducation, and patient-centered coaching to enhance treatment participation and engagement.
• Assist patients and families in understanding diagnoses, treatment recommendations, available services, and healthcare systems.
• Advocate for patient needs within the healthcare system and community service networks.
• Identify social determinants of health impacting patient outcomes and develop strategies to address identified needs.
• Conduct routine follow-up contacts with patients to monitor progress, reinforce treatment plans, and assess emerging concerns.
• Assist patients in navigating healthcare, behavioral health, social service, and community support systems.
• Collaborate with providers regarding patient safety concerns, changes in functioning, or…