Role Orientation: Care Coordinator

1. Purpose of the Role

Case Managers help clients bridge the gap between clinical care and real life. They provide practical support, resource navigation, and care coordination so that clients can access services, remain engaged, and move toward their goals.

2. Primary Duties

• Help clients identify and access resources (housing, food, transportation, benefits, medical care, school supports, etc.).
• Provide care coordination:
  • Communicate with external providers (with consent)
  • Support referrals and follow-up
• Assist with connecting to internal services (NP visits, lab work, LENS, therapy, groups).
• Provide supportive, skills-based check-ins within scope (NOT full psychotherapy).
• Document all contacts, attempted contacts, and coordination efforts in the EHR.
• Participate in team meetings and case consultations as needed.

3. Key Systems & Tools

• EHR for notes and task tracking
• Internal communication tools (secure messaging/email)
• Resource lists, local service directories, and any internal resource databases
• Phone, secure texting systems (if used by policy)

4. Supervision & Chain of Command

• Clinical and task oversight: assigned supervisor and/or Clinical Director
• Operational/logistics support: COO/site lead
• Escalation for safety/emergencies: NP, Clinical Director, supervisor

You are expected to consult when:

• Clients disclose significant risk or safety concerns
• Complex systems barriers arise
• You are unsure whether a task is within your scope

5. Scope & Boundaries

You can:

• Provide supportive and skills-based interactions
• Help with system navigation, advocacy, and coordination
• Reinforce treatment goals set by therapists/NPs

You must not:

• Represent yourself as a therapist (unless separately licensed and within that role)
• Provide psychotherapy or interpret labs/meds as if you were a prescriber
• Ignore safety concerns—these must be escalated and documented

6. RHC & Behavioral Health Connection

• You may support clients who are seen under both BH and RHC umbrellas.
• Some of your work may help justify care management or RHC-related codes (when used within policy and under appropriate supervision).
• Even if not billed directly as RHC, your documentation supports quality and continuity for RHC clients.

7. Success in This Role Looks Like

• Clients feel less “lost” and more supported in navigating systems.
• Coordination tasks are documented clearly and timely.
• You work closely with therapists and NPs without crossing into their scope.
• Safety concerns are elevated quickly and appropriately.