Provides clinical care coordination services to designated priority clients. The goal of the position is to help clients maintain stable community living, increase independence, and enhance quality of life in the community.
RESPONSIBLE TO: Program Manager
Bachelor's degree in relevant field and two years of experience with priority population
Demonstrated skills in assessment, crisis intervention, and clinical case management
Must be willing to work flexible hours based on clients' needs (including evenings and weekends), and to use own car for client transportation when needed
Must pass a criminal background and Inspector General check
TYPICAL DUTIES &
Assess needs of clients eligible for care coordination services and develops individualized service plans, including individualized and tailored care plans as appropriate. Meets regularly with ACM team and other involved persons to coordinate service planning.
Provides "supported/assertive outreach" and skill building needed for stabilization in the community (shopping, housing, payeeship, money management, medication support, supportive counseling). Provides flexible in-home support and skills teaching to prevent need for more restrictive placements. Uses wraparound funds, as needed, to address client service goals, particularly basic needs.
May provide group treatment, as negotiated with supervisor.
Assures access to needed vocational and other rehabilitative and treatment services, including chemical dependency services. Provides ongoing clinical assessment and supportive care to assure fit between client needs and services. Coordinates with other involved providers on a regular basis and documents.
Serves as care coordinator of record for caseload (size negotiated with supervisor). Works with team members to assure continuity of care and flexible intensity of services in accord with client needs.
Coordinates with and provides education and support to family members, caretaker, and others providing services to client. Coordinates treatment teams for high need clients.
Provides crisis intervention by phone and face-to-face as needed. Participates in crisis on-call system as negotiated and coordinates with Crisis Resolution Services as appropriate. Coordinates use of hospital during crisis episodes and facilitate alternatives to hospitalization utilizing respite and hospital diversion.
Is actively involved in treatment planning when client is hospitalized or placed. Coordinates discharge planning and works to assure continuity of care in accord with contract requirements.
Maintains timely records for clinical documentation and billing in accord with agency guidelines. Writes reports needed to help client access needed services and resources. Helps clients to maintain eligibility for entitlements and documents.
Meets with manager and/or clinical supervisor weekly and shares relevant issues. Accepts direction from supervisor. Meets regularly with psychiatric staff for consultation. Participates in team and agency meetings and work groups as negotiated. Receives relevant specialist consultation as required by WAC.
Develops working knowledge of community resources and coordinates with client and advocate groups as useful regarding service needs of client population. Works with manager and others to develop needed resources.
Identifies training needs and develops plans to maintain/further professional skills relevant to needs to priority population served.
Other duties to meet goals of the position.