Care Coordinator (78497)

Primary Responsibilities and Duties

- Screening, Assessment, and Engagement

- Establishes and maintains professional relationships with individuals, families, referral sources, and community partners.

- Completes initial and ongoing assessments in accordance with program, payer, and regulatory requirements.

- Identifies risk factors, including suicidal or homicidal ideation, and ensures immediate intervention, documentation, and follow-up in accordance with organizational protocols.

- Utilizes standardized screening tools (e.g., PHQ-9, SDOH assessments) as required.

- Care Coordination

- Coordinates services across healthcare, behavioral health, housing, employment, and social service systems.

- Facilitates communication among providers, natural supports, and community resources.

- Schedules appointments and assists with transportation coordination to reduce barriers to care.

- Participates in treatment team meetings and case reviews.

- Maintains timely, accurate, and compliant documentation in the electronic health record (EHR).

- Service Delivery and Support

- Provides targeted case management and supportive interventions consistent with scope of practice.

- Supports individuals in navigating systems of care and adhering to treatment recommendations.

- Promotes engagement in ongoing services and continuity of care.

- Advocates for individuals to ensure access to appropriate services and resources.