Integrated Care Navigator — Flexible Hours

MyCare Health Center; Mount Clemens (MI); On-site; USD 42,000 - 65,000; Full time

Benefits offered by this job

Student loan forgiveness

Paid holidays

Up to 160 hours PTO

Medical/dental/vision insurance

Life insurance

Long term disability

401K and Roth 401k

FSA

EAP

Job summary

MyCare Health Center seeks an Integrated Care Coordinator to support patients with complex medical, behavioral health, and social needs by coordinating services across primary care, behavioral health, SUD treatment, and community resources.

The coordinator promotes engagement in care, addresses barriers to treatment, and facilitates communication among an interdisciplinary team to improve health outcomes, managing a caseload of 50–100 patients depending on program complexity.

Qualifications

• Associate degree required; Bachelor's preferred; combination of education and experience may be considered.

Responsibilities

• Coordinate medical, behavioral health, dental, specialty, and community-based services to ensure continuity of care.
• Assist patients navigating the healthcare system, accessing resources, and resolving barriers to care.
• Facilitate referrals, schedule and confirm appointments, and close referral loops within 14 days whenever possible.
• Coordinate transitions of care after hospitalization, incarceration, detoxification, residential treatment, or ED visits, including 7-day follow-up.
• Conduct outreach via phone, text, and mail to engage and retain patients in care.
• Reduce no-show rates through reminders and barrier assessments.
• Develop and monitor individualized care plans with the interdisciplinary team; update every 90 days.
• Complete assessments and maintain timely documentation in the EHR within 24 hours.
• Monitor patient participation, goals, and progress; manage disengagement risk.
• Connect patients to housing, transportation, food, employment, insurance, legal, and recovery resources.
• Assist with enrollment and engagement in MAT, SUDHH, justice-involved programs.
• Support census growth through outreach and patient engagement.
• Track outreach, referrals, care plans, follow-ups, and program metrics.
• Participate in team meetings and coordinate with providers, staff, CHWs, partners, hospitals, and community agencies.
• Ensure compliance with HRSA, Medicaid, grant, payer and organizational requirements.
• Manage a caseload of approximately 50–100 active patients; maintain plan completion and documentation standards.
• Document outreach attempts within 24 hours and track engagement.

Skills

MOUD knowledge

Evidence-based practice

Communication skills

Public speaking

Nonprofit environment

Independent work

Volunteer training

Organizational skills

County resources (Macomb)

MS Office

Flexible hours

Problem solving

Education

Associate degree in social work / related field

Tools

Microsoft Office

Job description

MyCare Health Center seeks an Integrated Care Coordinator to support patients with complex medical, behavioral health, and social needs by coordinating services across primary care, behavioral health, SUD treatment, and community resources.

The coordinator promotes engagement in care, addresses barriers to treatment, and facilitates communication among an interdisciplinary team to improve health outcomes, managing a caseload of 50–100 patients depending on program complexity.