Integrated Care Coordinator

2 months ago

Lumberton, United States Southeastern Integrated Care LLC Full time
Job DescriptionJob Description

Job Summary:
The Social Work Integrated Care Coordinator is responsible for coordinating and providing comprehensive care to patients in an advanced medical home setting. This role focuses on bridging the gap between behavioral health and primary care needs, with an emphasis on inclusive and collaborative care management, chronic care management, and remote patient monitoring. The Social Work Integrated Care Coordinator works closely with interdisciplinary care teams to ensure the delivery of high-quality and patient-centered integrated care services. . Supports the mission and vision of our advanced medical home tier 3.


Essential Responsibilities and Duties:
1. Coordinate Care: Collaborate with behavioral health providers, primary care physicians, and other healthcare professionals to develop and implement integrated care plans for patients with complex medical and behavioral health needs.
2. Conduct Assessments: Conduct comprehensive assessments of patients' physical, behavioral, and psychosocial health status to identify individual needs and develop personalized care plans.
3. Care Planning: Develop and implement individualized care plans that address patients' physical, mental, and emotional health needs, focusing on chronic disease management and behavioral health interventions.
4. Collaborative Care Management: Facilitate communication and coordination between behavioral health and primary care providers to ensure seamless integration of services and promote holistic patient care. Acts a behavioral health care manager champion in accordance with NC collaborative care model:

  • Acts as Collaborative care behavioral health management champion / care manager.
  • Acts as CCM/RPM integrated care coordinator and onboarding of services
  • Acts as liaison between behavioral health clients in need of primary care via SEIC
  • Supports referral coordinator with medical and behavioral referrals as needed.
  • Supports quality metric adherence.

5. Chronic Care Management: Provide ongoing support and education to patients with chronic conditions, including monitoring medication adherence, lifestyle modifications, and

self-management techniques.
6. Remote Patient Monitoring: Utilize remote patient monitoring technology to monitor patients' vital signs, symptoms, and treatment adherence, and provide timely interventions as necessary.
7. Patient Education: Educate patients and their families on healthcare management strategies, self-care techniques, and available community resources to promote wellness and prevent hospital readmissions.
8. Documentation: Maintain accurate and up-to-date electronic health records (EHR) and documentation of patient encounters, care plans, interventions, and outcomes.


9. Quality Improvement: Participate in quality improvement initiatives to enhance the delivery of integrated care services and improve patient outcomes.
10. Professional Development: Stay updated with current trends and evidence-based practices in integrated care, behavioral health, chronic disease management, and remote patient monitoring through continuous education and professional development activities.

11. Other duties as assigned

Qualifications and Education:
- Certified Social Worker in the state of North Carolina preferred. (LCSW-A at a minimum) or

Registered Nurse (RN) license in the state of North Carolina. Bachelor of Science in Nursing (BSN) degree preferred.


- Minimum of 2 years of clinical experience in an integrated care or primary care setting.
- Experience in coordinating care between behavioral health and primary care providers.
- Strong knowledge of chronic disease management principles and evidence-based practices.
- Familiarity with remote patient monitoring technology and its application in healthcare.
- Excellent communication, interpersonal, and collaboration skills.
- Ability to work effectively as part of an interdisciplinary care team.
- Proficient in using electronic health record (EHR) systems.
- Commitment to providing patient-centered and culturally sensitive care.

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