Care Coordinator - AD Mobile

Position Summary:

As part of a multidisciplinary team, this position combines direct client care support with care coordination activities to improve health outcomes for individuals with opioid use disorder (OUD), substance use disorders (SUD), and co-occurring mental health conditions. The Care Coordinator assists with client intake, vital signs collection, lab draws, care gap closure, hospital and crisis follow-up, referral coordination, social service linkage, and client engagement activities for individuals receiving Medication for Opioid Use Disorder (MOUD). Services are provided primarily between the Mobile Behavioral Health Unit and the Clarke outpatient clinic.

Job Responsibilities and Performance Standards:

Medical Assistant Functions

• Room clients and prepare them for provider visits.
• Obtain and document vital signs, height, weight, BMI, and other required screenings.
• Collect and prepare laboratory specimens according to clinic protocols.
• Schedule and collect medical urine drug screens and record results according to clinic protocols.
• Document client information accurately in the Electronic Health Record (EHR).
• Report vital signs, screening results, and client concerns to the Registered Nurse (RN), prescriber, or other clinical staff.
• Perform medication logging, inventory, and release functions for Medication for Opioid Use Disorder (MOUD) and other prescribed medications in accordance with established protocols.
• Assist with maintaining efficient client flow throughout the clinic.

Care Coordination Functions

• Coordinate care for clients with chronic medical, behavioral health, and substance use disorders.
• Schedule appointments, referrals, consultations, diagnostic testing, and follow-up visits.
• Conduct appointment reminder calls and outreach to reduce missed appointments.
• Track referral completion and follow up on test results and treatment recommendations.
• Perform outreach to clients with identified care gaps and encourage preventive and follow-up care.
• Support management of high-risk populations through regular client engagement and monitoring.
• Utilize Electronic Health Record (EHR) systems to monitor client activity and coordinate care.
• Access and review EPIC Care Everywhere and hospital information exchanges to identify emergency department (ED) visits, hospital admissions, and discharges.
• Conduct follow-up calls after hospitalization, emergency department visits, psychiatric admissions, or crisis events.
• Collaborate with providers, nurses, care coordinators, and community partners to ensure continuity of care.
• Document all hospital and emergency department utilization, client contacts, interventions, and follow-up activities in the EHR. Track high-risk patients and support efforts to reduce avoidable emergency department utilization and hospital readmissions.
• Communicate relevant clinical information regarding ED visits and hospitalizations to providers, nurses, and care team members.
• Assist clients with accessing community resources, including housing assistance, transportation services, financial assistance, insurance enrollment, and public benefits.
• Facilitate referrals to medical, social service agencies and community-based organizations.
• Participate in crisis prevention activities and post-crisis follow-up efforts.
• Assist clients with prescription assistance applications and medication access programs.
• Maintain accurate documentation of all client contacts, outreach efforts, referrals, and care coordination activities.

Communication and Collaboration

• Work closely with physicians, nurse practitioners, physician assistants, nurses, behavioral health clinicians, and case managers.
• Participate in multidisciplinary team meetings and case reviews.
• Communicate effectively with clients, families, caregivers, community agencies, and healthcare providers.
• Demonstrate culturally competent, trauma-informed, and client-centered care practices.

Minimum Qualifications:

• High school diploma or GED.
• Medical Assistant certification and relevant healthcare experience.
• Minimum of one (1) year of experience in healthcare, behavioral health, public health, or community health setting.
• Basic knowledge of medical terminology and client care procedures.
• Proficiency with Electronic Health Records (EHR) and Microsoft Office applications.

Preferred Qualifications:

• Associate degree in Medical Assisting and related healthcare field.
• Experience in a Certified Community Behavioral Health Clinic (CCBHC), Federally Qualified Health Center (FQHC), community mental health center, or integrated care setting.
• Knowledge of behavioral health, substance use disorders, chronic disease management, and social determinants of health.
• Knowledge of Medication for Opioid Use Disorder (MOUD)
• Experience with care management, population health, or case management activities.