As a member of the clinical team, participates in the assessment and service plan development and implements services to recipients in accordance with their individualized service plan (ISP). Communicates and documents recipients progress toward their recovery. Creates and maintains a focus with each recipient in four areas: recovery, community, employment, and co-occurring disorders.
Primary Job Responsibilities
Education, Certification, and Experience Requirements
- Works collaboratively with the clinical team to engage, educate, communicate, and coordinate care with recipient, their family, behavioral and general medical and dental health care providers, community resources and others to ensure that all services prescribed in the individualized service plan (ISP) are implemented.
- Works with recipients to develop a role for themselves outside of their mental illness, while focusing on expected outcomes of increased employment, Meaningful Community Activity (MCA), independent living status, and social network, as well as decreased substance use/abuse.
- Provides supportive services including, but not limited to, the following:
- Assistance in maintaining, monitoring and modifying covered behavioral health services;
- Brief telephone or face-to-face interactions with a recipient, a recipients family, or other involved party for the purpose of maintaining or enhancing recipient functionality;
- Assistance in finding necessary resources other than covered services to meet basic needs;
- Serves as a point of contact and to ensure ongoing collaboration including the communication of appropriate clinical information with other involved parties as appropriate and coordination of care with a recipients family, behavioral and general medical and dental health care providers, community resources, and other involved supports including educational, social, judicial, community and other State agencies;
- Ensures all appropriate referrals for identified services on the service plan are made and coordinated with service providers via contracted network providers or community resources; Ensures all covered services identified on the service plan are evaluated and updated monthly.
- Provides outreach and follow-up of services including, but not limited to, crisis and missed appointments to ensure adequate resources are available and in place;
- Participates in staffing, case conferences or other meetings with or without the recipient or recipients family participating;
- Coordinates referral or completes the screening and assessment on all recipients on caseload for financial entitlements (AHCCCS, SSI/SSD etc.); completes AHCCCS applications on all recipients on caseload meeting criteria;
- Ensures that transfers to out-of-area, out-of-state or to an Arizona Long Term Care System (ALTCS) contractor, are coordinated as applicable;
- Ensures the development and implementation of transition, discharge, and aftercare plans prior to discontinuation of behavioral health services.
- Performs all case management functions associated with caseload including participating in the assessment and service planning processes; including identifying the need for further or specialty evaluations.
- Collaborates with the recipient and recipients family or significant others to implement an effective service plan, explaining the available clinical options to the team, including the advantages and disadvantages of each option.
- Maintains the recipients comprehensive clinical record, including documentation of activities performed as part of the service delivery process (e.g., assessments, provision of services, coordination of care, discharge planning).
- Provides continuous evaluation of the effectiveness of treatment through the ongoing assessment of the recipient and input from the recipient and relevant others resulting in modification to the service plan as necessary.
- Pursues best practice outcomes for recipient with mental illness including continuing education, employment, independent housing and community tenure.
- Provides transportation to recipient as appropriate and determined by the clinical team utilizing employees personal vehicle. Conducts frequent community visits, including but not limited to, private homes, jail facilities, office/clinic locations, hospitals, and group homes.
- Adheres to minimum productivity and documentation requirements.
Knowledge and Ability Requirements
- Bachelors degree in a social science field or equivalent combination of education, training, and/or experience meeting OBHL standards of BHT equivalent.
- Minimum of one year working with SMI adults.
- Maintain current CPR, First Aid, and CPI Certifications.
- Must be at least 21 years of age.
Thorough and working knowledge of psychiatric and co-occurring disorders is imperative. Knowledge of DSM-IV-TR codes and descriptions, psychotropic medications and crisis intervention. Requires effective interpersonal, written and verbal communication skills. Ability to follow direction, use of sound judgment and excellent time management skills are essential. Must maintain good recipient relationships, and be able to identify priorities and stay organized. Preferred typing skills of 25-30 wpm. Knowledge of community based behavioral health services preferred.
Tools and Equipment Requirements
Ability to use current electronic records management system. The ability to use a phone, computer, printer, and copier is required. Frequently uses Microsoft Office products, including but not limited to Outlook, Word, Excel, and PowerPoint. The ability to use the internet and various web browser software is required.