Integrated Care Coordinator

Conduct assessments and develop individualized, person-centered care plans based on client needs and Social Determinants of Health. Coordinate services across treatment teams, primary care providers, and community resources to ensure seamless delivery, while facilitating follow-up for hospitalizations and life transitions. Monitor client progress, track HEDIS gaps, and verify enrollment and payer status to maintain access to required services. Provide health education, crisis response support, and maintain accurate documentation of care coordination in accordance with regulatory standards. Support clinic operations including scheduling, reminders, and direct collaboration with Nurse Practitioners. Participate in marketing initiatives and outreach to promote program enrollment.