Behavioral Health Care Coordinator

Organization: Access Community Health Centers

Location: Madison, WI



The purpose of this position is to provide enhanced support to specific patient populations within Access to improve patient outcomes and support optimal care team communication and teamwork.  The Program Specialist will be housed within the Behavioral Health team, managed by the Primary Care Behavioral Health Manager under the Chief Behavioral Health Officer.  The patient populations will be identified by Access leadership with input from medical teams and will start with the following groups: 1) patients on Medication Assisted Treatment (MAT); 2) patients with Severe and Persistent Mental Illness (SPMI); and 3) patients with uncontrolled diabetes (a1>9) with comorbid mental health diagnosis that interferes with effective self-management. These groups have been selected to align with existing clinic initiatives and to assist in filling an identified gap in current services.  Additional patient populations, such as patients with uncontrolled diabetes, or other chronic medical conditions will likely be added in the future.  The Program Specialist will work closely with the Behavioral Health Consultants (BHC) and medical providers in their role of coordinating care.  Specific job duties will include the following.


  1. Technical
    1. Active management of list of patients on Medication Assisted Treatment. This includes:
      1. tracking the patients receiving MAT to monitor appointment attendance
      2. appropriate scheduling of follow up appointments
  • coordinating with care team on any needs to connect with specialty substance use counseling in the community
  1. outreach to specialty mental health providers in the community for coordination of care as needed
  2. outreach to patients in the event of no-shows or no follow-up appointment scheduled.
  1. Active management of patients with SPMI who need a higher level of care than can be provided in primary care. This includes:
    1. assisting patients in connecting with appropriate outpatient specialty mental health resources via their insurance, with active coordination of care between patients and community agencies.
    2. coordinating with area hospitals in the event of inpatient psychiatric admissions to coordinate appropriate discharge planning and connection to specialty mental health services.
  • coordinating with the County to advocate for patients to receive CCS or similar level of care if needed.
  1. working actively with patients to assist in engagement in outpatient services, as well as medical follow-up in primary care as needed.
  1. Active management of patients with uncontrolled diabetes with comorbid mental health diagnosis that interferes with effective self-management.
    1. Tracking patients who meet these criteria to monitor appointment attendance and engagement in care
    2. Outreach calls to patients to provide support, monitor follow through with goals, and schedule follow up appointments
  • Coordinating with care team to connect with specialty mental health services in the community
  1. Outreach to specialty mental health providers in the community for coordination of care as needed
  2. Coordinating with the care team on any needs
  1. Core Skills
    1. Effective telephone skills
    2. Organizational skills to manage patient lists
    3. Ability to coordinate care with BHC team and larger care teams
    4. Strong communication skills to use directly with patients and with care team members
    5. Strong writing skills for documentation and communication with care team members
    6. Computer skills including ability to navigate EPIC
    7. Program planning skills to be involved with ongoing development of case manager role
    8. Flexibility
    9. Timeliness and responsiveness
    10. Ability to work as a team player
    11. Ability to multi-task in fast-paced environment
    12. Strong patient/customer service skills
    13. Positive attitude
    14. Ability to maintain confidentiality
    15. Demonstrates cultural competence with patients and staff
    16. Open to continuous learning to build effectiveness


  1. Behavioral Standards


  • Able to develop and maintain effective relationships with clinical and administrative staff, patients, and community members.
  • Transmits clear, accurate, concise and relevant information to the right people at the right time. Chooses the most appropriate communication method, format, and tools to deliver information.
  • Communicates respectfully with patients and all staff based on shared goals and mutual respect.


  • Builds, maintains and draws from internal and/or external informal networks to better accomplish work.
  • Routinely coordinates and facilitates solutions with internal and external organizations and constituents.


  • Demonstrates empathy and objectivity during difficult situations/interactions and remains focused on solutions.


  • Listens to, understands and respects the differences of perspectives and backgrounds of colleagues and patients.
  • Shares their success with the team and openly recognizes the contributions of others.


  • Communicates with colleagues to streamline solutions and communicate program updates.
  • Overcomes difficulties by seeking and applying alternate methods to pursue work.
  • Seeks to gain an understanding of the rationale and implications of changes and takes appropriate measures to integrate these changes into work.
  • Understands role and its boundaries to work autonomously and involve leader when necessary.
  • Open to taking on additional tasks as assigned.


  • Demonstrates ability to make compromises to achieve results.
  • Effectively and efficiently plans work, while remaining sufficiently flexible to accommodate unforeseen changes.
  • Effectively manages multiple tasks according to their level of urgency and importance.
  • Plans project/work phases to meet deadlines while remaining focused on the end goal and purpose.
  • Puts measures in place to verify the accuracy and/or the quality of work.


  • Expresses themselves tactfully to create and maintain harmonious relationships and to facilitate the transmission of sensitive information.
  • Proposes solutions and works with others to resolve issues.
  • Shares relevant information with colleagues on a regular basis to support effectiveness and efficiency.
  • Understands how own work impacts the work of others and organizes work accordingly.


  1. Desired Requirements
    1. MSW in social work
    2. Bilingual preferred, not required