What are the responsibilities and job description for the Care Coordinator position at Family Health Center – Southwest Indiana?
Position Overview
The Care Coordinator supports individuals by taking comprehensive person-centered approach. This role helps connect behavioral health services, substance use treatment, primary care, and community‑based resources so people receive coordinated, consistent support across all areas of their health.
As a Care Coordinator, you assist in coordinating care across systems, settings, and providers, helping individuals understand their care, follow through with appointments, and address barriers such as transportation, housing, food access, or benefits. You work closely with internal care teams, healthcare providers, and community partners to support safe transitions, ongoing engagement in care, and improved health and stability over time.
The hours for this position would be 8 AM - 5 PM.
Essential Functions
The essential functions may include, but are not limited to the following:
- Perform routine referral, linkage, coordination, and monitoring of care across service providers.
- Facilitate transitions through warm handoffs between levels of care
- Monitor and support follow-up activities with treatment or service providers to track client engagement in care, including physician appointments, medication use, therapy, rehabilitation, and other supportive services.
- Coordinating care by referring to and communicating with external healthcare providers utilized by the client including PCPs, DCOs, pharmacies, labs, nursing homes, home health agencies, etc.
- Ensure every individual engaged in care is engaged with a primary care provider.
- Contribute to the development and updating of person-centered treatment/care plans
- Identify barriers to care and address social determinants (housing, transportation, food insecurity) Address social drivers of health by connecting individuals with social services, such as housing transportation, or food.
- Build rapport and support engagement in treatment
- Assist individuals receiving services with accessing benefits, enrolling in waivers, and connecting them with any other programs or support that may be beneficial.
- Support development and implementation of safety plans
- Coordinate with crisis teams and emergency services when needed
- Ensure timely follow-up after ER visits or hospitalizations (typically within 24–72 hours)
- Track admissions/discharges to other facilities and ensure continuity of care
- Track other services provided by outside entities such as medical care and medications prescribed by outside entities.
- Reduce Readmissions through proactive outreach
- Complete timely, accurate documentation in the EHR
- Participating in interdisciplinary team meetings
- Communicate effectively with clinicians, case managers, prescribers, and external partners
- Coordinate care provision with community agencies in support of the client (e.g. housing, legal, employment services)
- Ensure treatment and resources can be provided in a language or manner accessible to the individual receiving services
Work-Related Experience
- 1-3 years’ experience in behavioral health, case management, or care coordination preferred
- Experience working with high-risk or underserved populations preferred
Physical Demands and Work Environment
Mental:
- Ability to remain calm and effective in high-stress situations, such as medical emergencies or crisis interventions.
- Strong critical thinking and decision-making skills in dynamic patient care settings.
- Ability to communicate clearly both verbally and in writing within the organization and with outside agencies
- Ability to provide compassionate care while maintaining professional boundaries.
Physical:
- Sitting, standing, or walking for varied lengths of time.
- Lifting up to 20lbs.
- Ability to perform repetitive motions, including typing for EHR documentation.
- Occasional exposure to bodily fluids, infectious diseases, and hazardous materials; adherence to infection control protocols is required.
Working Conditions:
- Community settings as necessary or with other agencies.
- Clinical environment with exposure to infectious diseases, hazardous materials, and emotionally challenging patient cases.
- Potential for irregular hours, including evenings or weekends, depending on the role.
Education, Certification, and Licensure
- Education: Bachelor’s degree in social work, psychology, human services, or related field (required)
- Licensure: Valid Driver’s license; must be insurable under the organization’s vehicle insurance policy.
Skills
- Ability to establish rapport and build appropriate relationships with clients.
- Effective time management and organizational skills.
- Commitment to professional growth and supervision.
- Knowledge of integrated care models and trauma-informed care
- Understanding of mental health and substance use disorders
- Strong communication, organization, and problem-solving skills
- Ability to manage a high caseload and prioritize effectively
- Cultural competence and patient-centered approach