Care Coordinator

Responsible for

Under the supervision of the CCBHC Director and Program Manager, the Care Coordinator plays a central role in delivering integrated, person-centered care coordination services within a Certified Community Behavioral Health Clinic (CCBHC) model. This position combines direct client engagement, population health management, and data-informed care coordination to ensure timely identification, outreach, and intervention for individuals with behavioral health, substance use, and physical health needs across the CCBHC site.

The Care Coordinator collaborates closely with the CCBHC Director, SCHARP Programs, and CQI Analyst to ensure screening for risk, timely access to services, internal and external referrals, age-appropriate physical health screening for all participants, monitor key health indicators and risk factors, and coordinate linkage to primary medical care. The role also supports the accurate, timely, and complete collection of required quality measures data (including SUPRT data), ensuring alignment with CCBHC model of care, CARF accreditation, and SAMHSA quality care and federal reporting requirements.

Position Competencies

Position Requirements

• Bachelor’s degree in Social Work, Psychology, Public Health, Health Administration, or related field (Master’s preferred)
• Experience in behavioral health, integrated care settings, CCBHC, or FQHC settings.
• Experience working with diverse, low-income, and high-acuity populations.
• Proficiency in EHR/EMR systems and documentation standards.
• Valid driver’s license and ability to travel as needed.

Primary Duties

• Participate in the walk-in screening protocol, adhere to internal referral workflow processes, and utilize warm hand-off if possible and when appropriate.
• Raise awareness of our CCBHC through community outreach, outreach among care coordination partners, as well as to participate at in-person community events as assigned by CCBHC Director.
• Ensure children and older adults receive age-appropriate screening at respective CCBHC site.
• Provide high-touch care coordination to ensure individuals receive physical health screening and are linked fully to outpatient Primary Care Provider and dental services through the community.
• Ensure collection of complete SUPRT measures for all randomly selected consumers as part of the Crenshaw site sampling population, consistent with CCBHC Criteria 4.G., and that completed measures are delivered in a timely and complete manner to CQI Analyst, CCBHC Director, and Evaluator.
• Complete required training to serve as a Department of Health Care Services (DHCS) Coverage Ambassador.
• Coordinate care across: Behavioral health services; Primary care providers; Substance use treatment (including MAT/OUD services); Housing, DPSS Benefits, and social services.
• Ensure consumers are offered transportation assistance to reduce transportation as a barrier to accessible care.
• Serve as a health navigator and medical chaperone when appropriate and necessary to ensure access to linkages to meet the SDOH, health, and mental health needs of consumers.
• Serve as a liaison between consumers, family members, and various healthcare professionals.
• Educate consumers and their families on health conditions, preventive care, and lifestyle choices.
• Help consumers navigate the healthcare system, including scheduling with specialists, understanding medical bills, and coordinating transportation.
• When needed, accompany consumers to health-related appointments.
• Track and facilitate follow-up appointments, ensuring continuity of care and adherence to treatment plans.
• Monitor individualized care plans.
• Ensure follow-up on referrals and service linkages.
• Utilize dashboards and reports to identify and track:
• consumers overdue for physical health screenings (annual)
• consumers requiring 6-month treatment plan updates
• consumers with elevated PHQ-9 scores needing follow-up
• consumers screening positive on AUDIT-C