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 Clinical Care Coordinator is a licensed behavioral health clinician who supports members as they transition from Residential Treatment Centers (RTCs) back into the community. Working on behalf of IMBH and a Medicaid plan in Indiana, this role begins building the relationship before discharge and then carries a 90-day post-discharge caseload. The coordinator uses clinical judgment to evaluate whether each member's transition and aftercare plan is appropriate, complete, and working in practice, and helps close gaps before they lead to disengagement or readmission.
This role combines facility-based transition support with post-discharge clinical complex care management. Up to 75% of the week may be spent on-site at assigned RTCs, with the balance shaped by the needs of the active community caseload. Although an associate level behavioral health license and strong assessment skills are essential, this is a field-based clinical care management role rather than an ongoing outpatient therapy position.
What You'll Do
Post-Discharge Clinical and Complex Care Management (Primary)
- Carry a 90-day post-discharge caseload, initiate follow-up within required transition-of-care timeframes, and maintain contact at a frequency matched to each member's clinical needs and risk level.
- Complete a comprehensive complex care management assessment using a biopsychosocial lens. Assess behavioral and physical health needs, current symptoms and safety risks, functional status, medication access and adherence, substance use and recovery supports, psychosocial needs, social drivers of health, support systems, cultural and language needs, service utilization, strengths, preferences, and goals.
- Evaluate whether the member's transition-of-care plan has translated into appropriate aftercare. Confirm that the type, intensity, timing, and accessibility of services are sufficient, and identify gaps when the current plan does not match the member's needs.
- Develop and maintain a member-centered care plan with prioritized needs, measurable goals, interventions, a monitoring schedule, and clear follow-up. Revise the plan as the member's condition, goals, or circumstances change.
- Monitor clinical status, treatment participation, medication follow-through, appointment attendance, barriers, and outcomes. Recognize changes in risk or level-of-care needs and coordinate timely escalation with IMBH clinical leadership, providers, crisis services, or the Medicaid plan.
- Coordinate behavioral health, substance use, medical, pharmacy, recovery, and community-based services. Facilitate warm handoffs and help members secure the right level of therapy, psychiatry, medication-assisted treatment, or other aftercare.
- Engage family members, sponsors, and other support persons with member consent, and incorporate relevant information and supports into the care plan.
- Address barriers such as housing, food access, transportation, hygiene, benefits, pharmacy access, and connection to community resources or sober living.
- Document assessments, care plans, member contacts, clinical decisions, referrals, and transition-of-care activities clearly and within required timelines.
Embedded Transition Support
- Spend up to 75% of the week on-site at assigned RTCs based on facility coverage needs and the needs of the post-discharge caseload.
- Engage members before discharge, assess the clinical appropriateness and feasibility of the transition plan, and confirm that the member understands and can participate in the plan.
- Attend treatment team meetings and morning rounds and present structured case updates covering diagnosis, medication, risk, discharge barriers, aftercare needs, and the transition plan.
- Help secure timely follow-up therapy, psychiatry, substance use treatment, primary care, and other services, and confirm connections to preferred or aligned community providers before discharge whenever possible.
- Coordinate transportation, housing placement, benefits, medications, and other practical needs that could disrupt the transition from the facility to the community.
- Maintain collaborative relationships with facility staff, attending psychiatrists, community providers, and Medicaid plan care management and utilization management teams.
What You'll Bring
- Strong clinical assessment and care planning skills, including the ability to synthesize complex behavioral, medical, functional, and psychosocial information into an actionable plan.
- Experience supporting individuals with serious mental illness (SMI), substance use disorders, or co-occurring conditions across transitions of care.
- Sound clinical judgment and confidence assessing safety, treatment adequacy, service intensity, and changes in level-of-care needs.
- The ability to build trust with members who may be in crisis, unhoused, ambivalent about care, or difficult to reach.
- Strong organization and follow-through across multiple facilities, community visits, providers, and an active caseload.
- Clear, objective clinical documentation and confidence presenting cases in treatment team, care management, and utilization management settings.
- Knowledge of Indiana behavioral health and community resources, social drivers of health, and discharge coordination.
- A trauma-informed, person-centered approach that respects member choice and centers the member's goals.
Requirements
- Master's degree in social work, counseling, marriage and family therapy, or a related behavioral health field, or a doctoral degree in clinical or counseling psychology.
- Current, active, and unrestricted Indiana license as a Social Worker (LSW), Mental Health Counselor Associate (LMHCA), or Marriage and Family Therapist Associate (LMFTA) or independent clinical practice as an LCSW, LMHC, LMFT, or licensed psychologist with an HSPP endorsement. The license must be maintained throughout employment.
- At least 2 years of behavioral health experience, including experience with clinical assessment, complex case management, care coordination, or transitions of care.
- Reliable personal vehicle and willingness to travel regularly to assigned RTCs, member locations, provider offices, and community settings.
- Ability to pass a comprehensive background check and drug screening.
- Ability to meet all facility requirements, including health screenings and vaccinations required by assigned RTCs.
- CPR/First Aid certification or willingness to obtain before start.
- Authorization to work in the United States without visa sponsorship.
What Will Make You Stand Out
- Prior experience in an RTC, inpatient behavioral health unit, psychiatric hospital, or community mental health setting.
- Experience conducting biopsychosocial or complex care management assessments and building integrated care plans.
- Experience with Medicaid managed care, behavioral health transitions, or health plan care management requirements and quality measures.
- Familiarity with Motivational Interviewing, trauma-informed care, harm reduction, or recovery-oriented practice across facility and community 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: $34.00 - $42.00 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?
- Do you possess an active license to practice behavioral health in Indiana? If so, please enter your license type.
Work Location: In person
