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.

• Essential duties & responsibilities
• 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.