DEFINITION:
Demonstrates a high level of clinical expertise in one's ability to provide outpatient care navigation services to adults, children, and families at NorthCare. The position is responsible for ensuring that a continuum of health and behavioral healthcare is provided along with increasing patient/family involvement as partners in their own health. This position is expected to meet productivity guidelines, as outlined by the outpatient management team.
SUPERVISION:
Position is supervised by Program Supervisor.
ESSENTIAL JOB FUNCTIONS INCLUDE, BUT ARE NOT LIMITED TO:
- Provide integrated services that are welcoming, engaging, accessible and in the community. These services address physical healthcare, behavioral healthcare and social needs that are recovery focused, strengths based, culturally competent, patient centered, trauma informed, and co-occurring capable.
- Promotes a warm and engaging organizational culture in line with NorthCare values, trauma informed care, and health and wellness.
- Demonstrates clinical expertise in coordinated health and behavioral health care. Able to care coordinate complex cases using a multitude of evidence-based interventions including wellness resources, rehabilitation curriculum and case management strategies. Has an excellent understanding abd ability to assist one's program in meeting state and federal health care measures. Works independently and provides mentorship to colleagues regarding care coordination. As needed, leads care coordination staffing's focused on population management needs.
- Works as part of a multi-disciplinary team to support health behavior change in persons with behavioral health challenges. Interact and collaborate in a genuine and professional manner with the patients, their families, support system and community partners to assist with obtainment of treatment goals.
- Work with patients to obtain and maintain eligibility for health and disability benefits, obtain and maintain affordable housing in a community of choice, arrange reliable transportation, locate and enroll in education or vocational programs, find and keep a job, locate needed services/resources and build a natural support system, and follow up to ensure services are received.
- Provide preventive interventions, linkage and advocacy for services and health information related to smoking cessation, nutrition, exercise, weight management, stress management, and chronic disease management.
- Work within and outside the agency to coordinate care across various treatment milieus. Help prepare people for primary care appointments and increase self-management and goal planning.
- Demonstrates a breadth of knowledge and expertise about resources and benefit programs.
- Provide crisis management services, this may include face-to-face or telephone interviewing of the patient; assessment of lethality to self or others; assessment of available support systems; and assistance in arranging for appropriate intervention, including hospitalization. In the cases where a potential for harm exists, will consult with management staff or available therapist to develop a safety plan with the patient.
- Transport patients to various locations in the community and provide services in the home.
- Monitor and track outcome measures for client caseload.
- Maintain clinical records in a timely manner, as required by agency policy, funding sources and accreditation authorities. Complete all required forms and maintain same in a manner consistent with requirements.
- Maintain professional competency in the area under one's responsibility through appropriate readings, attendance at workshops and trainings. Comply with all requirements to maintain professional certification(s). Knowledgeable regarding: NorthCare's electronic record system and public folders; CCBHC requirements, ODMHSAS Services manual, contract requirements, and benchmarks; National Outcome Measures (NOMS); Medicaid rules and regulations.
- Return phone calls and cell text pages promptly. Check and respond to email daily.
- Maintain consistent work attendance and contact supervisor on timely basis for needed late arrivals or absences. Meet dress code expectations.
- Complete all NorthCare required courses and training and comply with all agency policies and procedures, including but not limited to confidentiality requirements, documentation deadlines and productivity expectations.
- Performs any reasonable work requested that falls within the qualifications but not specifically described in work performed.