Behavioral Health Care Coordinator

The Behavioral Health Care Coordinator(BHCC) works as a key member of the Integrated Behavioral Health (IBH) Team and in collaboration with the Interdisciplinary Teams (IDT) for the region as part of Innov Age’s Program of All-Inclusive Care for the Elderly (PACE). Our IBH team functions largely as a Consultation Liaison service and consists of the BHCC, licensed therapists (PsyD, PhD, LPC, LCSW, LMFT), internal Psychiatric Mental Health Nurse Practitioners (PMHNP), and externally contracted licensed behavioral health providers.

The BHCC is responsible for coordinating internal and external behavioral health referrals, navigating a patient panel for individual support with participants under the guidance of licensed teammates, and managing licensed clinicians’ time for in-person and telehealth assessments and interventions across centers. The BHCC also serves as a resource to multiple centers across the region, helping with onboarding, creation of education materials, data tracking, verifying out-of-network claims, scheduling intakes for behavioral health consultations, and attending meetings with IDT, participants, and families.

Essential Functions and Work Responsibilities

Duties may include, but are not limited to:

Functional Category: Direct, Participant Facing Care

Estimated Percent of time Spent –35%

• Provides direct service for participants through supportive check-ins and completion of screeners for assigned participants with identified behavioral health needs.
• As a non-licensed teammate, direct patient contact is limited to interactions to include selecting and completing appropriate screeners, active listening, normalization and validation of feelings, motivational interviewing, safety planning, and specific psychoeducation as directed by a licensed clinician.
• Participants with new or worsening symptoms, based on parameters set by a licensed clinician, will be re-escalated to licensed BHP for further management and stabilization.

Functional Category: Coordination of Care

Estimated Percent of time Spent – 35%

• Fields internal referrals for Behavioral Health services to ensure adequate and appropriate referral information, working with Primary Care Providers (PCP), members of the IDT, surrogate decision-makers, and the rest of the IBH team to gather additional information as needed.
• Coordinates care for in-person and telehealth appointments for PMHNPs and BHPs.
• Facilitate outside behavioral health referrals as ordered by PCPs and reviewed by BHPs.
• Collaborates with external behavioral health services as single point contact for updates on participants care, and relays medical records to Innov Age clinic staff and health information management (HIM).

Functional Category:IDT Collaboration

Estimated Percent of time Spent –20%

• Collaborates with entire IDT on case consultation.
• Coordinates care with the participant’s primary care provider, appropriate interdisciplinary team members, and appropriate behavioral health providers.
• Fosters communication with center staff, monitoring potential behavioral health needs.
• Serving as behavioral health first contact for participant crises that arise in home center to deescalate and provide 1:1 support, stabilizing participant until physician or licensed behavioral health provider can intervene.

Functional Category: Administrative

Estimated Percent of time Spent –10%

• Maintains accurate and timely documentation and paperwork including participants’ electronic medical records according to policies and procedures.
• Researches and verifies out of network claims related to behavioral health across centers.
• Updates and maintains data on onboarding and employment maintenance requirements.
• Updates and maintains data on IBH referrals, participant panels, touchpoints, and staffing.
• Updates and maintains data on Clinical Value Initiatives.
• Supports the Behavior Health team across the region with other assigned duties as needed (administrative, auditing, projects, etc.)

Physical Demands and Work Environment

Stand (choose one):☐ Never ☐Occasionally ☒Frequently ☐Continuously

Sit (choose one): ☐ Never ☐Occasionally ☒Frequently ☐Continuously

Walk (choose one): ☐Never ☒Occasionally…