Responsible for care coordination duties in collaboration with  identified clients, their formal and informal natural supports, treatment team, Center staff, and community partners in a team-based approach to promote timely access to appropriate individualized care, increase utilization of preventative care, increase client satisfaction and quality of life,  and reduce emergency room utilization and hospital readmissions. The Care Coordinator will serve as the point of contact, advocate, and informational resource for clients, treatment team, family/caregiver(s), and community resources to facilitate care of the client throughout the continuum of care. Works under moderate supervision of the Care Coordinator supervisor, with access to assigned clinical supervisor, with latitude for the use of initiative and independent judgment within the Texas LVN Scope of Practice.  Primary duties include, but are not limited to:

• Assists in assessing the need for, and accessing medical, social, educational, and other appropriate services.
• Identify and link clients with community resources to facilitate and follow up on referrals and respond to client’s evolving needs.
• Increase clients’ ability for self-management and shared decision making through culturally and linguistically appropriate education.
• Increase continuity of care by developing and managing relationships with internal and external care providers.

• Coordinates and monitors service delivery.
• Contributes to the development of the Person-Centered Recovery Plan in collaboration with client and treatment team.
• Linking and/or assisting clients with services and supports for Crisis Prevention and Management
• Track and support clients through points of transition.
• Collaborates with multidisciplinary team to ensure clients’ holistic needs are met effectively and efficiently.

• Maintains and updates all electronic health records, documents, and tracking data.
• Collects and enters data in alignment with SAMHSA SPARS data reporting requirements and federal guidelines in an accurate and timely manner.