The Care Coordinator, CCBHC (Certified Community Behavioral Health Clinic) helps members navigate and access community services and other resources, adopt healthy behaviors, improve health outcomes, and reduce healthcare costs.

• Monitors and facilitates access, engagement and beneficial use of services and resources for Thresholds CCBHC members.
• Screens and assesses members for current mental health, physical health, and substance use disorders.
• Serves members with behavioral health needs; reviews skills, connects to resources, educates on mental illness, chemical dependency disorders, and treatment, and discusses care plans.
• Calls members who miss appointments to check in and address any barriers.
• Follows up with collateral providers, including pharmacies to facilitate and improve continuity of care.
• Makes referrals to outside providers. Creates and develops relationships with community providers to promote availability of affordable behavioral health resources not provided by Thresholds.
• Identifies gaps in care for members and arranges appropriate and timely resolution with internal and external agencies.
• Documents member care and related communications in the electronic health record.
• Establish and oversees a process for communicating pertinent patient information and status reports to designated Thresholds and community healthcare providers, including the CCBHC Medical Director, consulting psychiatrists and medical professionals.
• Uses service data, appointment information and other key indicators to achieve care coordination.
• Attends and participates in clinical team and administrative meetings as necessary.
• Identifies risk factors related to relapse and develops relapse prevention plans and strategies.
• Advocates for members who may be vulnerable or need additional support.
• Provides member education on common mental health, physical health, and substance use disorders.
• Participates in regularly scheduled caseload consultation. These consultations will primarily focus on members who are new to treatment, difficult to engage, or who are not improving as expected.
• Supports medication management
• Completes the NOMS (National Outcome Measures) and submits them in a timely manner.
• Other duties as assigned.

• May be required to work flexible schedules and be available to work on weekends or evenings as required.

• Must, at a minimum, meet Office of Mental Health Rule 132 credential requirements for a Mental Health Professional:
  • High school diploma or GED certificate and 5 years of supervised clinical experience
  • Bachelor's degree in Psychology, Social Work, or related field
  • Bachelor's degree in an unrelated field and 2 years of supervised clinical experience
  • Active Certified Recovery Support Specialist credential (CRSS)
• Master's degree in social work, counseling, psychology or closely related field preferred.

• Experience working with persons diagnosed with mental illness preferred.
• Ability to document services provided in an Electronic Health Record in a timely manner.

• Current and valid driver's license.
• Daily access to a personal vehicle is required. Must obtain and maintain $100,000/$300,000/$100,000 bodily injury and liability insurance. Subject to validation every six months.
• May be required to provide transportation for members of the program using a Thresholds provided vehicle or personal vehicle. Must be 23 years of age and must meet all insurance carrier's requirements. Subject to annual Department of Motor Vehicles license verification.