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Intergrated Care Coordinator

Department: 1144 - Paul Elizondo Primary Care
Location: San Antonio, TX
Work Schedule: M-F: 8:00 a.m. - 5:00 p.m.


 The Integrated Care Coordinator manages, coordinates and supports the delivery of integrated physical and behavioral health care (including substance use), supervises interaction of team members to ensure continuous collaboration and enhancing communication, supervise peer support specialists, develop and coordinate all wellness programs, leads weekly team meetings and case reviews, collects and analyzes data to identify changes in clinical indicators, helps manage use of medications prescribed by PCP, especially treatment adherence, side effects and treatment effectiveness, is trained in all health promotion interventions.   The target population for services is individuals with severe and persistent mental illness as well as substance use disorders. Using a patient-centered approach which removed silos of care and supports an integrated system; this position will provide whole-person care coordination across medical, behavior and social service community systems.


Coordinate services between the Integrated care team and community services as needed to ensure that both current disease, as well as preventative and health promotion needs are addressed as part of the holistic, whole –person, culturally-sensitive health approach. 

  1. Link and refer consumers presenting to clinic to appropriate services (internal and/or external) as requested by the medical team and explain purpose of appointments in clear and simple language. Promote importance of social supports and good lifestyle choices.
  2. Establish and maintain routine collaborative meetings between Integrated Care and system partners toward achieving benchmark standards and improving patient care.
  3. Educate patients about health issues relevant to their care, community health resources, insurance information, financial assistance, pharmaceutical services, etc. 
  4. Participate in Quality Improvement activities, including data collection, tracking, and analysis.
  5. Synthesize information from treatment records, risk stratification, and other sources to assess program enrollees. Apply evidence-based clinical guidelines for behavioral and physical health issues, in addition, knowledge of care coordination techniques in assessing the needs of recipients and determining interventions to address those gaps.
  6. Demonstrate excellent customer service and collaborate with physicians, providers, consumers, staff members, visitors, staff, and the health care community.
  7. Collaborate with Health Home Team and treating providers in developing and implementing care coordination plan to address treatment barriers.
  8. Demonstrate flexibility in job duties and schedule in order to aid in better serving the organization, the consumers, and to assist reaching benchmark standards set forth by the Center for Health Care Services. Allow for flexibility in scheduling to accommodate crisis situations for patients.
  9. Attend regularly scheduled meetings and training sessions to enhance team performance.
  10. Uses available data, such as exams/assessments scores, participant evaluations, and service observations to identify health and wellness needs to develop care coordination plans.
  11. Participates in various work group and committee activities to support departmental and organizational efforts to improve the quality of services throughout our systems of care.
  12. Supervision of Peer Support Specialist staff and interns, including giving ongoing feedback and formal performance evaluations. 
  13. Creation of informational tools and resources for clients and staff on mental health, physical health, and integrated health services. 
  14. Development and coordination of all wellness programming (on-site and off-site), including promotion of activities, tracking attendance, evaluations, and topic. Delivery of wellness education programs. 
  15. Comply with and participate in Quality Assurance and Quality Improvement processes.
  16. Keep records, complete reports, and track required paper work from relevant team members.
  17. Other duties as assigned


  1. Master's degree from an accredited university or college in a Behavioral Health field OR Associates degree or higher in Nursing.
  2. Must have and  maintain current license in good standing in the State of Texas as a Licensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT,) or Current Registered Nurse Certification to practice in the State of Texas and two years of nursing experience, with at least one year in psychiatric, mental retardation, or substance abuse setting.
  3. For RN’s, knows and conforms to the Texas Nurse II Practice Act and the Board's rules and regulations as well as all Federal, State, and local laws, rules, or regulations affecting the RN's current area of nursing practice.
  4. Must be able to be credentialed with all Center payors   
  5. Proficiency with standard Microsoft Office applications and system databases
  6. Must maintain required credentials and mandatory training requirements to ensure compliance with all State regulations and CHCS policies
  7. Must maintain a valid driver’s license and automobile insurance coverage, be able to travel as needed, and be able to meet on a consistent basis the driving record requirements of the Company’s auto insurance carrier if you drive your vehicle during company business 
  8. Must be able to meet the physical requirements to complete SAMA and CPR training including lifting up to 12 lbs. and supporting up to 55 lbs.; bending, stooping and getting on and off the floor without assistance.
  9. Must have  adequate mobility that requires frequent walking, standing, bending, stooping, kneeling, reaching (vertical and horizontal), using fingers, hands, feet, legs and torso in various care. The employee must be able to regularly lift and/or move up to 40 pounds and occasionally must lift and/or move up to 50 pounds. The employee must be able to occasionally     transfer a consumer.



  1. Two (2) years’ experience providing similar services
  2. Bilingual in English and Spanish


Compensation Package 


Recruiting and retaining talented individuals is important to us. At the Center for Health Care Services, we are committed to providing our employees with a total compensation package that includes competitive pay, affordable health and wellness benefits, generous paid time off, flexible work schedules, professional development opportunities and generous retirement savings options. 

 We have wide range of career opportunities and hope you will join us in our mission! 

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