IHH Care Coordinator / BHC - ACCESS Holy Cross

Position Summary

The Behavioral Health Consultant (BHC) .60 FTE is part of a multi-disciplinary primary health care team. BHCs are responsible for providing behavioral health consultation and treatment to children, adolescents, and adults to improve their psychosocial functioning and overall health outcomes.

The Integrated Health Home (IHH) Program Care Coordinator is a Licensed Social Worker .40 FTE, who provides care coordination, education, social support services and outreach services to assist patients in navigating health care transitions, and support patient empowerment through health education, advocacy, and coaching. The person in this position has proven SMI experience and provides care coordination with a Triple Aim approach in mind: Improve the patient experience, improve population health, and lower the cost of health care. The role works primarily with patients with Serious Mental Illness (SMI).

Core Job Responsibilities

• Oversees the intake process, maintains care plans, and promotes health programs and services.
• Utilizes information systems to contact, educates, and engages and tracks patients based on disease risk, self-management, and family/community needs.
• Assists patients and providers in transitioning between outpatient and inpatient settings, ensures post-emergency, hospitalizations, and specialist follow-ups.
• Provides resources to support patient and family self-management, assesses readiness to learn, and validates learning outcomes.
• Engages patients and families in care decisions, encourages questions and concerns, and recognizes their expertise through coaching and counseling.
• Conducts screenings, assessments, and diagnosis of mental health conditions while identifying barriers to achieving optimal physical health.
• Assesses crises and implements appropriate interventions to support patient well-being.
• Identifies at-risk patients and develops plans to prevent further psychological or physical deterioration.
• Delivers brief, focused interventions for mental and behavioral health concerns.
• Participates in meetings that support the integrated healthcare model and comprehensive patient care.
• Performs other duties as assigned.

Requirements/Preferences

• Master’s degree required.
• Required license: LCPC, LCSW or LMFT and current unrestricted licensure in Illinois.
• Three (3) to five (5) years of experience in a clinical setting and previous care coordination preferred.
• Excellent working knowledge of evidence-based mental health and behavioral inventions.
• Proficiency in Electronic Health Record (EHR) and EPIC Preferred
• Intermediate proficiency in Microsoft Office Suite (Word, Excel, PowerPoint).

Working Conditions/Equipment

• Normal office environment regularly and health center occasionally  
• Requires local travel between clinical/health centers, hospitals, and community sites. A valid driver’s license and proof of insurance are required when using a personal vehicle.
• For remote or hybrid roles, a secure remote work environment with a reliable, high-speed internet connection is required.
• Ability to sit and work at a computer for up to four (4) hours and lift up to 10lbs.
• Computer/laptop, phone, fax, copier, scanner.