Integrated Care Coordinator, CoCM – Care Management and Behavioral Health

Essen Health Care is the largest privately held, multispecialty medical group in New York, providing high-quality, compassionate care to some of the state’s most vulnerable and underserved residents.

Founded in 1999, we’ve grown from a single primary care office into a network of 50+ locations offering urgent care, primary care and specialty services, from women’s health to endocrinology and psychiatry. We also provide nursing home support, care management, and in-home care through our Essen House Calls program. Guided by a Population Health model, our team of 500+ providers deliver care in-person, at home, or via telehealth, ensuring patients get the support they need when and where they need it.

We’re looking for talented, motivated individuals to join our growing team. Whether you’re a medical provider, administrator, or operations professional, there’s a career here for you. Join us in making a real difference in the health of our community.

Position Title: Integrated Care Coordinator,  Behavioral Health

Job Summary: The Integrated Care Coordinator, Behavioral Health is a care management and coordination role bridging care management agency services and Collaborative Care Model (CoCM) behavioral health programs. You will carry a caseload from care management agency members requiring care planning, coordination, and both remote and in-person support; and CoCM patients requiring screening, brief evidence-based interventions, registry management, and close collaboration with the Psychiatric Consultant and primary care provider. 

This role is ideal for a motivated individual — including new graduates — who is passionate about serving underserved, multicultural communities within a high-impact, team-based integrated care environment. We actively welcome and support candidates early in their careers who bring energy, commitment, and a strong foundation in human services or social work.

Core Responsibilities 

Behavioral Health and Care Management Support 

• Conduct intakes and develop individualized, person-centered care plans for care management agency members. 

• Screen and assess for common behavioral health conditions using PHQ-9, GAD-7, and other validated tools to guide care planning and appropriate triage. 

• Provide brief evidence-based interventions including behavioral activation, motivational interviewing, and problem-solving techniques. 

• Support monitoring of treatment plan progress, including documentation of adherence, changes in symptoms, and coordination with clinical supervisors. 

• Provide culturally responsive, trauma-informed support reflecting the diversity of communities served. 

Care Coordination and Patient Engagement 

• Serve as the primary point of contact for patients on both care management and CoCM caseloads. 

• Conduct telephonic and in-person outreach, follow-up, and engagement; conduct in-person visits as required (home, office, or community-based). 

• Schedule appointments with PCPs, Psychiatric Consultants, and external specialists or community providers. 

• Identify and address social determinants of health — connect patients with housing, food, transportation, benefits enrollment, and community resources. 

• Facilitate referrals for clinically indicated services outside the organization (vocational rehabilitation, substance use treatment, social services). 

Registry, Documentation, and Team Collaboration 

• Maintain the CoCM patient registry — tracking enrollment, PHQ-9/GAD-7 scores, treatment milestones, and follow-up status. 

• Prepare patient summaries for weekly Systematic Case Review (SCR) with the Psychiatric Consultant. 

• Document all patient interactions accurately and timely in the EHR per care management agency and CoCM billing and regulatory requirements. 

• Participate in team huddles, case reviews, and quality improvement meetings within your assigned care team. 

Education 

• Bachelor's degree required in Social Work, or Human Services, or Psychology, or a related behavioral health or social sciences field. 

• Master’s degree in social work or related field is a plus but not required. 

• New graduates are encouraged to apply. We are committed to developing early-career professionals with the right foundation and motivation. 

Experience 

• Minimum 1 year of experience in a behavioral health setting (e.g., outpatient mental health, substance use, crisis services, community health); OR 

• Minimum 2 years of experience in case management, care coordination, or human services, with meaningful exposure to behavioral health populations. 

• New graduates with relevant field placement, internship, or practicum experience in behavioral health or care management are strongly encouraged to apply. 

• Familiarity with validated screening tools (PHQ-9, GAD-7) and evidence-based approaches (motivational interviewing, behavioral activation) is a plus. 

• Experience working with underserved, multicultural, or Medicaid-insured populations highly desirable. 

Skills and Other Requirements 

• Strong communication, engagement, and organizational skills; ability to build rapport with patients in a care coordination relationship. 

• Proficiency with EHR systems and patient registries; strong documentation skills for billing and compliance. 

• Bilingual English/Spanish strongly preferred. 

• Reliable transportation required for in-person patient visits. 

• Commitment to Essen Health Care's mission of serving vulnerable and underserved communities. 

Work Environment 

This is a full-time, on-site role based in the Bronx, NY. Regular travel to Essen Health Care offices and community sites across New York City is required as part of patient care responsibilities.

• Essen Health care is proud to be an equal opportunity employer, and we seek candidates who desire to work in and serve an ethnically diverse population.