Organization: Innovative Behavioral Health
Setting: Residential Treatment Centers (RTCs) in Indiana - Fort Wayne and Henryville/Jeffersonville
Work Model:In-Person / On-Site
Schedule: Full-Time
About the Role
The Embedded Care Coordinator (ECC) is a full-time, in-person role based within Residential Treatment Centers (RTCs) in Indiana. Working on behalf of IMBH and a Medicaid plan in Indiana, the ECC is embedded inside the facility treatment team, partnering daily with members, clinicians, social workers, and discharge planners to ensure every member has a safe, well-coordinated transition out of the facility and into the community.
In areas where a dedicated Community Care Coordinator (CCC) is not yet in place, this role operates as a Hybrid Care Coordinator, carrying both the inpatient ECC responsibilities and a 90-day post-discharge community follow-up caseload. Where both roles exist, the ECC and CCC work closely together, with the ECC supporting simpler post-discharge cases and remote follow-up alongside ongoing facility work.
What You'll Do
Embedded Care Coordination (Primary)
- Spend at least 75% of each week on-site at assigned RTCs, engaging in person with members, attending treatment team meetings, and collaborating with facility clinical staff.
- Complete an assessment with every admitted member at the first opportunity; begin discharge planning on day one.
- Attend treatment team meetings and morning rounds; present structured case updates covering diagnosis, medication, discharge barriers, and tentative plan.
- Schedule follow-up therapy and psychiatry appointments within 7 days of discharge and confirm connections to preferred or aligned community providers before the member leaves.
- Identify and engage collateral contacts (family, sponsors, support persons) with member consent, and incorporate that information into the care plan.
- Coordinate transitions of care: arrange transportation, confirm housing placement, and address barriers to post-discharge follow-through.
- Consult with IMBH clinical leadership on level-of-care decisions and escalate high-risk members, including those with recent or 30-day readmissions.
- Maintain positive, collaborative relationships with facility staff, attending psychiatrists, and Medicaid plan case managers and utilization management staff.
- Document all member engagements and transition-of-care plans within 48 hours of each encounter.
Community Care Coordination (Hybrid Responsibilities)
In hybrid assignments or where a dedicated CCC is not available, the following post-discharge responsibilities are added to this role:
- Carry a 90-day post-discharge caseload; contact members within 7 days of discharge and maintain engagement at a frequency matched to member acuity.
- Meet members in person in the community and develop individualized care plans within the first 30 days post-discharge; update every 60 days.
- Address social determinants of health (SDOH): housing, food access, transportation, hygiene, and connection to community-based services and sober living.
- Coordinate and assist with transportation to outpatient appointments, pharmacy, and community resource centers.
- Monitor treatment adherence and follow-up appointment attendance, and provide motivational support for recovery milestones.
What You'll Bring
- Experience working directly with individuals experiencing serious mental illness (SMI), substance use disorders, or co-occurring conditions.
- Strong interpersonal skills and the ability to build trust quickly with members who may be in crisis, unhoused, or disengaged from care.
- Confidence contributing in clinical settings such as treatment team meetings and rounds.
- Strong organizational skills and ability to manage a multi-facility schedule alongside an active caseload.
- Clear, objective documentation; ability to write compliant clinical notes and present cases in a structured format.
- Familiarity with community resources, SDOH navigation, and discharge coordination.
- Proficiency with electronic health records or care management software.
- A trauma-informed, person-centered approach to member engagement.
Requirements
We value relevant experience over formal credentials. Candidates from a variety of backgrounds are encouraged to apply, including those with experience as a Community Health Worker, Behavioral Health Technician (BHT), SMI Case Manager, Peer Support Specialist, discharge planner, or in a similar direct-care or care coordination role.
- At least 1 year of experience in behavioral health, case management, care coordination, or a closely related field (required).
- Bachelor's degree in social work, human services, psychology, nursing, or a related field preferred; equivalent experience will be considered.
- Reliable personal vehicle and willingness to travel daily to assigned RTC facilities.
- Ability to pass a comprehensive background check and drug screening.
- Ability to meet all facility requirements, including health screenings and vaccinations as required by assigned RTCs.
- CPR/First Aid certification or willingness to obtain before start.
- Must be authorized to work in the United States without visa sponsorship.
What Will Make You Stand Out
- Prior experience in an RTC, inpatient behavioral health unit, or psychiatric hospital setting.
- Experience conducting bedside engagement or discharge planning.
- Familiarity with Motivational Interviewing or trauma-informed care frameworks.
- Comfort working across both facility-embedded and community-based care settings.
IMBH is an equal opportunity employer. We do not discriminate on the basis of race, color, religion, national origin, sex, gender identity, sexual orientation, age, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law.
Pay: $23.25 - $28.00 per hour
Benefits:
Application Question(s):
- Do you live in or are willing to commute to Henryville, Jeffersonville, or Fort Wayne?
- Are you willing to work directly with clients in-person at facilities and in their community?
Work Location: In person
