Integrated Care Coordinator

About the Role

At Pinnacle Family Services, a member of Health Connect America, Integrated Care Coordinators serve as key connectors for children, youth, and families, linking clients, providers, and community resources to ensure comprehensive behavioral and physical health support. The role is hands‑on, relationship‑driven, and essential to client outcomes and program success. You will balance in‑office responsibilities with community‑based engagement, supporting both ongoing wellness and crisis intervention while collaborating closely with treatment teams, integrated‑care staff, and external partners.

Responsibilities

• Conduct assessments and develop individualized, person‑centered care plans based on client needs, health goals, and Social Determinants of Health (SDOH).
• Coordinate and monitor services across treatment teams, primary care providers, and community resources to ensure seamless care delivery.
• Facilitate follow‑up services for recent hospitalizations, life transitions, or other critical events to support smooth transitions of care.
• Monitor client progress, track HEDIS gaps, and verify enrollment and payer status to ensure access to all required services.
• Provide health education, guidance, and crisis‑response support to clients and their families as needed.
• Maintain timely, accurate documentation of care coordination, assessments, and interactions in accordance with regulatory and agency standards.
• Support clinic‑based operations, including scheduling, reminders, vitals, chart documentation, and direct collaboration with Nurse Practitioners for integrated‑care clients.
• Participate in marketing initiatives, outreach to new referrals, and education of prospective clients to promote engagement and program enrollment.
• Ensure all care‑coordination activities comply with Health Connect America policies, state regulations, and program standards, adhering to timelines and proactive monitoring to maintain high‑quality service.

Qualifications

• Must meet North Carolina Qualified Professional (QP) requirements per 10A NCAC 27G .0104.
• One of the following education/experience combinations:
  • Master’s degree in a human services field + 1 year of relevant experience.
  • Bachelor’s degree in a human services field + 2 years of relevant experience.
  • Bachelor’s degree in a non‑human‑services field + 4 years of relevant experience.
• Current North Carolina license (including provisional) or board‑issued certification in a human services profession.
• Experience must be full‑time and supervised, serving children and adolescents with a primary mental‑health diagnosis; experience may be accumulated before or after degree completion.
• For care‑manager positions serving members with LTSS needs: at least two years of prior LTSS and/or HCBS coordination, care‑delivery monitoring, and care‑management experience, in addition to the above requirements. This experience may overlap with two years of direct work with individuals with behavioral‑health conditions, an intellectual/developmental disability (I/DD), or a traumatic brain injury (TBI).

Benefits

• Comprehensive benefits package supporting professional and personal well‑being.
• Flexible scheduling and a culture that values work‑life balance.
• Employee Assistance Program (EAP) with eight mental‑health counseling sessions annually.
• Paid time off and paid holidays for full‑time employees.
• Medical, dental, vision, and voluntary insurance options.
• Health Savings Account (HSA) with company contribution.
• Dependent daycare flexible spending account.
• Access to a Health Navigator.
• 401(k) retirement plan.
• Benefits Hub and Tickets at Work – exclusive savings and perks for everyday life.