Care Coordinator

Role Summary

At Midwest Integrated Care (MWIC), the Care Coordinator ensures patients receive comprehensive, coordinated support across behavioral health and primary care services. This role is central to care planning, advocacy, and outcome tracking, while supporting compliance and quality standards. The care coordinator is the primary individual with whom the patient can develop a trusting relationship, and who will help the patient navigate and fully participate in his/her own healthcare.

Key Responsibilities

Care Planning & Coordination

• Support the mental and physical health care of patients on an assigned patient caseload. Closely coordinate care with the patients providers and community resources.
• Conducts biopsychosocial assessments and screenings.
• Develops and maintains individualized care plans.
• Provides patient education about common mental health and substance use disorders and the available treatment options.
• Supports psychotropic medication management as prescribed by medical providers, focusing on treatment adherence monitoring, side effects, and effectiveness of treatment.
• Provides brief behavioral interventions using evidence-based techniques such as problem-solving treatment, motivational interviewing, or other treatments as appropriate.
• Facilitates referrals to resources and/or additional treatment as clinically indicated.
• Develops patients self-management skills through education and resource provision.
• Participates in regularly scheduled caseload consultation, communicating treatment recommendations.

Compliance & Documentation

• Completes orientation and continuing education as appropriate.
• Documents patient progress and treatment recommendations in the EHR to be shared with medical providers, behavioral health providers, and/or other treating providers.
• Facilitates treatment plan changes as scheduled or when a patient is not improving as expected in collaboration with other treating providers.
• Develops and completes relapse prevention self-management plans with patients who have achieved their treatment goals and are soon to be discharged from the caseload.
• Ensures documentation meets Joint Commission, HIPAA, and 42 CFR Part 2 requirements.
• Participates in incident reporting, complaint resolution, and risk management as appropriate.

Outcome Tracking & Advocacy

• Monitors patient progress, updates care plans and ensures continuity after hospitalizations or transitions.
• Tracks patient follow-up and clinical outcomes via the EHR for value-based care initiatives.
• Advocates for patient rights, safety, and access to services.

Qualifications

• Bachelors degree in social work, nursing, or related field required; licensure preferred.
• Experience in care coordination or behavioral health.
• Ability to effectively engage patients in a therapeutic relationship.
• Ability to maintain effective and professional relationships with the patient and other members of the care team.
• Working knowledge of diagnosis of common mental health and/or substance use disorders, when appropriate.
• Experience with assessment and treatment planning for common mental health and/or substance use disorders.
• Effective communication, organizational, collaboration, and documentation skills.
• Knowledge of integrated behavioral health models and brief psychosocial interventions (e.g., motivational interviewing, problem-solving treatment, behavioral activation).