The Behavioral Health Clinical Care Coordinator will conduct outreach and perform assessments for Northwest Colorado residents, specifically those enrolled in Medicaid and Medicare throughout the Yampa Valley. They will be the primary point of contact for residents with complex medical/behavioral needs. Care coordination activities will focus on supporting member’s medical, behavioral, and socioeconomic needs to promote appropriate utilization of services and improved quality of care.

This position will serve as a liaison between clients and healthcare providers including specialty providers and human service organizations to reduce barriers to care and assure clients receive the care they need when they need it. The Behavioral Health Clinical Care Coordinator is a member of the Care Coordination team and works with clients to identify barriers to care, and develop a comprehensive goal-oriented care plan. 

Supervision Received: The Behavioral Health Clinical Care Coordinator is based out of our Routt or Moffat offices and is supervised by the Care Team Director.

Supervision Exercised: none

Key Accountabilities & Essential Duties

Conduct outreach and provide assessment of Routt, Moffat, and Rio Blanco County residents who are enrolled in Medicaid and Medicare

• Provide a variety of indirect and direct care coordination to clients identified as in need of services. This includes:

• Form trusting collaborative relationships with clients and partner organizations and care coordinator II.

• Schedule and complete assessments, follow-up as needed, track results, referrals and recommendations in database.
• Meet with clients in public spaces or place of residence when appropriate to the clients’ needs.
• Track and monitor referrals of clients for reporting as requested.
• Accurately document interactions in population health data system (ESSETTE) to include client visits, needed services, phone calls, written correspondence and communication in appropriate computer system within 2 business days.
• Work closely with partner organizations such as Horizons, Lift Up, Department of Human Services and other members of the Navigation Network to complete care plans.

• Ability to connect with diverse client population, empathize, show compassion, perform assessments and develop and self-management plan in partnership with client and possibly other community partner agencies.
• Coordinate care with providers, community partners and other patient navigators to provide outreach, referrals and support for Medicaid clients.
• Complete documentation and reporting as required by program and supervisor.

• Complete intakes of high-risk patients, working in partnership with patient, family and other members of the healthcare team as needed to assess and prioritize patient’s physical needs, mental well-being, family support system, financial resources and available community and government resources.

Educate and work with clients to develop a comprehensive, goal-oriented care plan, including identifying barriers to care

• Co-create patient specific goals, objectives and measures that meet the patient’s needs and that have been identified through assessment.

Ensure that clients are connected to resources and community partners identified in their care plan

• Provide technical assistance to CCT across the region around ESSETTE and work with Rocky to improve the data and reporting system.

• Collaborates with other Care Coordinators to ensure all program deliverables are being met and advise supervisor or CCT Coach of any needs for meeting deliverables such as monthly reporting, referrals, interventions, assessments, etc.

Collaborate with Care Team Supervisors and other Care Coordinators to ensure all program deliverables are achieved and program evaluations are conducted

• Participate in regular staff meetings.
• Performs assigned work safely, adhering to organization and program established safety rules and practices.

Assess and document effectiveness of care plans and share with Care Team Supervisor

• Serve as liaison for Rocky Mountain Health to support a strong connection between RCCO/RAE, CCT and NCCHP. Share information in a proactive way with team and supervisor.
• Conduct program evaluation tools within program requirements (client evaluations, success stories and work with CIVHC).

Required Qualifications:

• Current, unrestricted independent licensure as a RN, LPC, or LCSW in Colorado or a master’s level BHC Degree
• 2 years of Behavioral Health Experience
• 1 years of experience with MS Office, including Word, Excel, and Outlook

• Working with clients, clinical practices, community social service providers, complex medical patients and knowledge of health service delivery preferred
• Ability to communicate effectively with diverse audiences including clients, community members, professional partners, funders and government agencies 
• High level of organizational skills with a focus on problem solving, detail oriented and follow through 
• Active listening, motivational interviewing techniques, and the ability to support clients during intense emotional periods

• Perform all other duties as assigned

General Requirements:

• BSN, Master's Degree or Higher in the Behavioral Health or related field
• 1 years of community case management experience coordinating care for individuals with complex needs 

• Experience working in team-based care
• Background in Managed Care
• Health or Human Services experience preferred
• Share unique skills and expertise with NCCHP team 
• Engage in cross-organization efforts, connecting project work to the broader organization.

• Support non-clinical community care team
• Commitment to inclusiveness, social justice, health equity and reduction of health disparity
• Identifying and using data for data informed decision making, and to enhance collaborative work
• High tolerance for ambiguity and ability to problem solve and appropriate course of action
• Knowledge of Maternal Child Health including screenings tools, developmental milestones, 

immunizations, etc)