Chicanos Por La Causa, Inc.

Phoenix, Arizona, United States

Integrated Care Coordinator

Posted over 1 month ago

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Job Description

Mesa, AZ


The Integrated Care Coordinator functions as a core member of an interdisciplinary team that involves the members' primary care provider, behavioral health medical provider, other healthcare providers and ancillary staff, with a focus on management of individuals with high cost/high needs, more complex conditions and those who are not progressing as expected. The Integrated Care Coordinator advocates for and supports to ensure access to necessary services needed to increase wellness self-management and reduce emergency room visits and/ or hospitalizations.


To be considered a qualified behavioral health technician or a behavioral health paraprofessional, a person must have one of the following combinations of education, license and/or behavioral health work experience:
  • Bachelor's degree in behavioral health related field required. Minimum of 2 years behavioral health work experience preferred.
  • Bachelor's degree in non-behavioral health related field and 30 semester hours in behavioral health education and two years behavioral health work experience.
  • Associate's degree in behavioral health related field and four years behavioral health work experience.
  • Associate's degree in non-behavioral health related field and 30 semester hours in behavioral health education and five years behavioral health work experience.
  • Has a high school diploma or equivalent and 18 credit hours of post-high school education in a field related to behavioral health completed no more than 4 years before the date of proposed employment and 2 years full time behavioral health experience OR 4 years of behavioral health work experience.
  • Specialized training, certificate or experience in primary or emergency care.

  • Understands basic medical terminology, medication and diseases that affect service population.
  • Demonstrated competency in written, verbal, and computational skills to present and document records in accordance with program standards.
  • Experienced in and demonstrated comprehensive understanding and working knowledge of the interdisciplinary planning process and the developmental treatment model
  • Excellent organizational/time management skills with the ability to manage multiple priorities.
  • Strong assessment and motivational interviewing skills.
  • Ability to take initiative and see tasks to completion.
  • Working knowledge of computer software and electronic health record systems.
  • You must have the ability and willingness to regularly travel, in some instances with clients in Agency or personal vehicle.

  • Carries a short-term caseload of 1:15 20 comprised of individuals who are frequent utilizers of inpatient and emergency department settings, and others with more complicated care needs as determined by the treating BHMP and PCP.
  • Serves as an added resource to the assigned case manager to facilitate individual engagement and follow up in care, understand and implement post-discharge/post-visit medical orders and to coordinate more specialized post-discharge/post-visit placements (including skilled nursing centers, home health, and residential settings).
  • Participates in regularly scheduled interdisciplinary team meetings to review and update member's individual comprehensive service/care plan to ensure coordination and communication with involved specialty and inpatient providers.
  • Monitors members (in person and by telephone) for changes in clinical symptoms and treatment side effects or complications and communicates back to the RN, BHMP and PCP teams.
  • In collaboration with the member's case manager, facilitates treatment plan changes for members who are not improving as expected in consultation with the behavioral and medical teams. These may include changes in medications or psychosocial treatments or appropriate referrals for additional services. Works with the member's case manager to implement treatment plan changes and updates.
  • Provides support and education to families and natural supports on treatment options.
  • Provides telephonic as well as face-to-face outreach, engagement, and service planning in the field.
  • Maintains documents, records, statistics, and other related reports in an organized, timely, and accurate manner as per policy and procedure.
  • Track member follow-up, Gaps in Care report and clinical outcomes using the EMR.
  • Monitors overall service delivery to clients to ensure coordination and continuity; advocates with service providers/resources as needed.
  • Provides crisis intervention and follow-up.
  • Maintain satisfactory punctuality and attendance as set on the work schedule
  • Comply with required workplace safety standards
  • Comply with company incident reporting procedures.
  • Participate in regular staff meetings, required training programs, clinical supervision, etc.
  • Maintain confidentiality and adherence to HIPAA regulations at all times.

  • Bachelor's in behavioral health preferred
  • Education or experience as a Medical Assistant, Certified Nursing Assistant, medical social worker, medic or previous medical and behavioral health case management.


Employee will be expected to participate in continuous learning, competency building and maintenance of competency skills.


Ability to communicate clearly and effectively both verbally and in writing.


Work is performed in structured environments and field based locations.


Sitting for long periods Driving

Standing for long periods Kneel

Lifting 0-30 lbs. Bend Stoop

Typing Traveling

Alternative work hours (Between 5:00p.m.-8:00a.m.)

Working on a computer 4- 6 hours a day


  • Car, valid AZ Driver's License, company set minimum insurance coverage and ability to meet and maintain the company acceptable driving requirements. Must be willing to transport members using own personal vehicle and company vehicles.


Reports to and is supervised directly by the Clinic Director or Clinical Coordinator. Employee is also accountable for understanding and complying with CPLC policies and procedures.