Care Coordinator

The Care Coordinator plays a pivotal role in supporting the client’s treatment journey—from initial intake through discharge planning—ensuring that all aspects of care are well-coordinated, documented, and aligned with individualized treatment goals. Depending on the needs of the facility, the Care Coordinator may focus primarily on intake, discharge, or both functions. This position acts as the central liaison among clinical, medical, and support staff ensuring smooth transitions, continuity of care, and adherence to state and Joint Commission standards.

ESSENTIAL DUTIES & RESPONSIBILITIES

INTAKE & ADMISSION

· Conduct initial screenings and biopsychosocial assessments to determine severity of substance use and co-occurring mental health conditions.

· Perform new client orientations, reviewing the Participant Handbook, program expectations, and facility rules.

· Collaborate with the interdisciplinary treatment team (NP, therapist, RSS, nursing) to determine level of care and develop preliminary treatment goals.

· Ensure all intake documentation, consents, and clinical assessments are accurately completed and entered into the EMR.

· Coordinate with the medical team to obtain physician orders and ensure initial labs, screenings, and evaluations are completed, per policy. 

CARE COORDINATION

· Serve as the communication hub between clients, their care team, and external providers.

· Maintain up-to-date documentation in the client’s record to reflect coordination of care activities, treatment plan reviews, and follow-up contacts.

· Facilitate interdisciplinary team meetings to review client progress, update ASAM criteria, and modify treatment plans.

· Support clients in developing SMART goals and linkages to appropriate community or aftercare resources.

· Track utilization review processes, authorizations, and updates to ensure ongoing payer compliance.

DISCHARGE PLANNING

· Initiate discharge planning upon admission, incorporating aftercare needs into the Master Treatment Plan.

· Collaborate with the client and clinical team to ensure continuity of care post-discharge.

· Coordinate with external facilities, outpatient programs, housing, and peer support services to support client reintegration.

· Review and document discharge instructions, confirming client understanding of medication and follow-up care requirements.

· Complete discharge summaries and ensure all documentation meets minimum clinical documentation standards.

CRISIS AND BEHAVIORAL MANAGEMENT

· Recognize signs of crisis, escalating behaviors, or safety concerns and follow established de-escalation and emergency procedures. · Collaborate with the treatment team to develop individualized behavior plans when needed. · Participate in and document behavioral interventions, safety planning, and transfer coordination during crisis events.

QUALIFICATIONS AND KNOWLEDGE

· Strong understanding of behavioral health, substance use disorders, and trauma-informed care principles.

· Excellent written and verbal communication skills, with attention to documentation accuracy and timeliness.

· Knowledge of ASAM criteria, clinical documentation standards (SOAP, DAP, or BIRP formats), and utilization review requirements.

· Ability to collaborate effectively across interdisciplinary teams and maintain confidentiality under 42 CFR Part 2 and HIPAA.

· Demonstrated ability to manage multiple priorities with professionalism and empathy.

EDUCATION AND EXPERIENCE

· Bachelor’s degree in social work, psychology, human services, or related field required; master’s degree preferred.

· Minimum two (2) years of experience in behavioral health or substance use treatment setting.

· Experience with intake coordination, case management, or discharge planning preferred.

· Certification or licensure in a behavioral health discipline (CADC, LBSW, LMSW, etc.) preferred.

· Current CPR and First Aid certification (or ability to obtain within 30 days of hire).

KEY COMPETENCIES

· Client Advocacy: Ensures client voice and choice are central in treatment decisions.

· Clinical Judgment: Applies sound judgment to evaluate needs, risks, and treatment recommendations.

· Communication: Maintains clear, compassionate, and professional communication with clients and staff.

· Documentation: Produces timely, complete, and compliant records aligned with state and Joint

Commission standards.

· Collaboration: Works cooperatively within interdisciplinary teams to promote whole-person care.

· Ethical Conduct: Upholds professional boundaries and confidentiality at all times.

WORK CONDITIONS/PHYSICAL AND MENTAL REQUIREMENTS

· Indoor, controlled environment with exposure to clients experiencing emotional or behavioral distress.

· Frequent sitting, standing, and use of computer systems; occasional lifting of up to 25 lbs.

· Regular contact with others through in-person, phone, and electronic communication.

· May encounter contagious or infectious conditions; adherence to infection control and safety protocols is required.

PERFORMANCE EXPECTATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. 

· Completes intake and discharge documentation within policy timeframes.

· Demonstrates consistent adherence to care coordination workflows.

· Actively participates in interdisciplinary team meetings and clinical reviews.

· Maintains compliance with agency policies, state regulations, and accreditation standards.

· Promotes a professional, compassionate environment consistent with trauma-informed principles.

EQUAL OPPORTUNITY STATEMENT

We are an Equal Opportunity Employer and value diversity and inclusion. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, veteran status, genetic information, or any other characteristic protected by applicable law. We are committed to creating an inclusive environment for all employees.