Full Job Description
Position: Substance Use Disorder Care Coordinator
Department: Behavioral Health
Reports To: Director of Behavioral Health
Position Status: Non-exempt
The Substance Use Disorder Care Coordinator works as part of the medication-assisted treatment (MAT) team. This role is responsible for coordinating and supporting substance use disorder treatment within the clinic and for coordinating referrals to clinically indicated services outside the clinic. The Care Coordinator focuses on engaging patients in their own care through consistent assessment, measurement of progress, outreach, education, group work and referral management efforts. Patient engagement occurs both in person as well as telephonically. The position is best suited for energetic, empathetic, and organized individuals, who thrive in a team-based environment.
Duties and Responsibilities
1. Provide proactive outreach and encourage MAT patients to become actively engaged in their own health through calm, compassionate communication and by utilizing techniques such as motivational interviewing and behavioral activation.
2. Support and closely coordinate substance use disorder treatment care with the MAT PCP and, when appropriate, other behavioral health providers.
3. Track patient follow-up and clinical outcomes. Document patient encounters and use the worklist to identify and re-engage patients who are not participating as expected in their treatment.
4. Facilitate recovery plan changes for patients who are not improving as expected in consultation with the PCP and substance use disorder treatment provider. These may include changes in medications, psychosocial treatments, or appropriate referrals for additional services.
5. Participate in daily huddle before clinic start time and be able to discuss each patient’s progress.
6. Facilitate referrals for clinically indicated services outside the primary care clinic (e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment, etc.).
7. Complete relapse prevention plan with patients who are in remission.
8. Attend ongoing training and learning related to job position and duties.
9. Work with LCSW/LCPC and PCP in a collaborative manner to ensure that all patients in MAT program
receive the supportive services that they need to achieve their treatment goals.
10. Work with providers in other care settings (hospitals, emergency rooms, treatment centers) to improve communication during transitions of care.
11. Participate in marketing MAT service when census is low in the program.
12. Help MAT patients access social services that will help them address the social determinants of their health status.
13. Work with QI team to improve outcomes on HEDIS measures related to population health through calling back patients for routine care and participating in huddles.
Required Skills or Abilities
1. Demonstrates ability to collaborate and communicate effectively in a team setting.
2. Ability to maintain effective and professional relationships with patients and other members of the care team.
3. Displays high energy, empathy, and organization skills on a daily basis.
4. Ability to effectively engage patients in a therapeutic relationship, when appropriate, by telephone or face-to-face.
5. Experience with or ability to learn assessment tools and treatment planning for common mental health and/or substance use disorders, when appropriate.
6. Ability to travel locally, from clinic to clinic, when necessary.
7. Work flexible work schedules, which could include nights and weekends, when necessary.
8. Experience working with underserved, transient populations.
9. Experience working with patients who have co-occurring mental health, substance abuse, and physical health problems.
10. Experience with screening for common mental health and/or substance use disorders.
1. Must be able to remain in a stationary position 50% of the time.
2. Must be able to move around the clinic site 50% of the time.
3. Constantly operates a computer, computer printer, copy machine, and telephone.
4. Occasionally positions self to maintain exertion of physical strength to move objects of 10 pounds from one level to another.
5. Must be able to transport from one site to another.
6. Must be able to cover other shifts as necessary.
7. Ability to move as needed to perform necessary nursing skills such as wound care, injections, and other procedures
Required Knowledge, Experience, or Licensure/Registration
1. Bachelor’s degree in social work, psychology or relevant field, with 1-3 years related experience.
2. CADC or past work experience with patients struggling with a substance use disorder, preferred.
3. Fluent English/Spanish, preferred.
PrimeCare Health is firmly committed to creating a diverse workplace and is proud to provide equal employment opportunities to all applicants. Therefore, PrimeCare does not discriminate on the basis of creed, color, national origin, sex, gender identity, sexual orientation, age, religion, marital or parental status, alienage, disability, political affiliation or belief, military or military discharge status.