Integrated Care Coordinator, CoCM – Care Management and Behavioral Health

Core Responsibilities

• Conduct intakes and develop individualized, person-centered care plans for care management agency members.
• Screens and assesses for common behavioral health conditions using PHQ-9, GAD-7, and other validated tools to guide care planning and appropriate triage.
• Provide brief evidence-based interventions including behavioral activation, motivational interviewing, and problem-solving techniques.
• Support monitoring of treatment plan progress, including documentation of adherence, changes in symptoms, and coordination with clinical supervisors.
• Provide culturally responsive, trauma-informed support reflecting the diversity of communities served.
• Serve as the primary point of contact for patients on both care management and CoCM caseloads.
• Conduct telephonic and in-person outreach, follow-up, and engagement; conduct in-person visits as required (home, office, or community-based).
• Identify and address social determinants of health — connect patients with housing, food, transportation, benefits enrollment, and community resources.
• Facilitate referrals for clinically indicated services outside the organization (vocational rehabilitation, substance use treatment, social services).

Registry, Documentation, and Team Collaboration

• Maintain the CoCM patient registry — tracking enrollment, PHQ-9/GAD-7 scores, treatment milestones, and follow-up status.
• Prepare patient summaries for weekly Systematic Case Review (SCR) with the Psychiatric Consultant.
• Document all patient interactions accurately and timely in the EHR per care management agency and CoCM billing and regulatory requirements.
• Participate in team huddles, case reviews, and quality improvement meetings within your assigned care team.

Education and Experience

• Bachelor's degree required in Social Work, or Human Services, or Psychology, or a related behavioral health or social sciences field.
• Master’s degree in social work or related field is a plus but not required.
• New graduates are encouraged to apply.
• Minimum 1 year of experience in a behavioral health setting (e.g., outpatient mental health, substance use, crisis services, community health); OR Minimum 2 years of experience in case management, care coordination, or human services, with meaningful exposure to behavioral health populations.
• Familiarity with validated screening tools (PHQ-9, GAD-7) and evidence-based approaches (motivational interviewing, behavioral activation) is a plus.
• Experience working with underserved, multicultural, or Medicaid-insured populations highly desirable.

Skills and Other Requirements

• Strong communication, engagement, and organizational skills; ability to build rapport with patients in a care coordination relationship.
• Proficiency with EHR systems and patient registries; strong documentation skills for billing and compliance.
• Bilingual English/Spanish strongly preferred.
• Reliable transportation required for in-person patient visits.
• Commitment to Essen Health Care's mission of serving vulnerable and underserved communities.