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Complex Care Coordinator

Cadillac, MI


Posted on August 13, 2018

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About Complex Care Coordinator


Provides care management, care coordination, and counseling for patients with complex behavioral health conditions. Able to work in addressing complex social, emotional, and educational needs in the primary care setting, under minimal supervision. Serves in an expanded health care role to collaborate with PCP, specialists, members of the health care team, and patients/families to ensure the delivery of quality, efficient, and cost-effective health care services. Assesses plans, implements, coordinates, monitors and evaluates all options and services with the goal of optimizing the patient’s health status with a focus on supporting self-management skills and improving mental health outcomes. Integrates evidence-based clinical guidelines, preventive guidelines, and protocols, in the development of individualized care plans that are patient-centric, promoting quality and efficiency in the delivery of health care.


  • Works with team to identify the targeted high risk population within practice site(s). Includes patients with repeated social and/or mental health crises.

  • Assesses over time the health care, educational, and psychosocial needs of the patient/family. Uses standardized assessment tools such as depression screening, functionality, and health risk assessment.

  • Must have knowledge of the impact of Adverse Childhood Experiences (ACEs) and the ability to integrate ACEs and Resilience interventions within the integrated practice of care.

  • Collaborates with PCP, patient, and members of the health care team, including continuum of care settings and community. Responsible for developing a comprehensive individualized plan of care with targeted interventions. Continually monitors patient/family response to plan of care, and revises the care plan as indicated.

  • Provides patient self-management support with a focus on empowering the patient/family to build capacity for self- care.

  • Implements systems of care that facilitate close monitoring of high-risk patients to prevent and/or intervene early during acute exacerbations, including hand off to other mental health providers.

  • Implements clinical interventions and protocols based on risk stratification and evidence-based clinical guidelines.

  • Coordinates patient care through ongoing collaboration with PCP, patient/family, community, and other members of the health care team. Fosters a team approach and includes patient/family as active members of the team. Takes the lead in ensuring the continuity of care which extends beyond the practice boundaries. Serves as liaison to acute care hospitals, specialists, and post-acute care services.

  • Demonstrates excellent written, verbal, and listening communication skills, positive relationship building skills, and critical analysis skills.

  • Maintains required documentation for all counseling and care management activities.

  • Works with practice and PO/PHO leadership to continuously evaluate process, identify problems, and propose/develop process improvement strategies to enhance care management and Patient Centered Medical Home delivery of care model.

  • Reviews the current literature regarding effective engagement and communication strategies, care management strategies, and behavior change strategies and incorporates into clinical practice.

  • Implements and maintains the Integrated Behavioral Health program’s philosophy, principles, and procedures in all facets of performance.


  • Demonstrates customer focused interpersonal skills to interact in an effective manner with practitioners, the interdisciplinary health care team, community agencies, patients, and families with diverse opinions, values, religious beliefs, and cultural ideals.

  • Demonstrates ability to work autonomously and be directly accountable for practice.

  • Demonstrates ability to influence and negotiate individual and group decision-making.

  • Demonstrates ability to function effectively in a fluid, dynamic, and rapidly changing environment.

  • Demonstrates leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, critical thinking, analysis skills and decision-making, priority setting, work delegation, and work organization.

  • Demonstrates ability to develop positive, longitudinal relationships and set appropriate boundaries with patients/families.


  • Support the mission, vision, and values of the organization.

  • Treat others and their ideas with respect and dignity.

  • Set a good example for others.

  • Be an active coach for everyone in the organization.

  • Maintain the highest standards of honesty, integrity, and communication.

  • Insist on excellence and be accountable to one another.

  • Build group cohesiveness and pride through teamwork.

  • Demonstrate confidence in Wexford PHO and its workforce in all areas of the community.

  • Value and promote creativity and the change process.

  • Be a good communicator and listener; be available and visible.

  • Develop yourself to your highest potential.

  • Active participation in Quality Initiatives.

Required Qualifications:

  • Master’s degree and license in human services field required. MSW or MA in psychology or counseling. LMSW or Doctoral LP preferred with 3 years or 6000 hours related work experience.

  • Fully licensed in good standing in the State of Michigan as a Mental Health Professional.

  • Preferred experience with outpatient or inpatient mental health counseling; Preferred experience in medical social work, discharge planning, and crisis assessment for psychiatric level of care placement.

  • Demonstrated knowledge and proficiency in best practice treatment of Mental Health Disorders.

  • Two years of experience with adult medicine and patients in primary care/ambulatory care, home health agency, skilled nursing facility, or hospital medical-surgical setting, within the past five years

  • Knowledge of chronic conditions, evidence based guidelines, prevention, wellness, health risk assessment, and patient education

  • Critical thinking skills and ability to analyze complex data sets. Ability to manage complex clinical issues utilizing assessment skills and protocols

  • Excellent assessment and triage skills. Ability to implement evidence base interventions and protocols

  • Demonstrates excellent communication–both verbal and written

  • Excellent interpersonal and facilitation skills

  • Ability to affect change, work as a productive and effective team member, and adapt to changing needs/priorities

  • Time management, priority setting, work delegation and work organization.

  • General computer knowledge and capability to use computer

Preferred Qualifications:

  • Experience as a participant in continuous quality improvement

  • Completion of self-management support training

About Munson Medical Center

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