PRIMARY ROLE OBJECTIVE: Coordinates the overall Whole Person Health plan of care for patients with mild to moderate emotional, behavioral and SDOH challenges. Oversees patient needs evaluation and assists in treatment planning, monitors patient progress, adjusting treatment plans as necessary. Acts as a liaison between patient/family and service delivery personnel to ensure patients are being effectively treated. Evaluates social needs and connects the patient and family with available services and coping resources.
MAIN DUTIES & RESPONSIBILITIES:
1. Functions as an important member of the Care Team in Team Based Care.
2. Participates in periodic Case Conferences with other healthcare professionals to develop comprehensive care plans for improved health.
3. Participates in morning huddles to identify opportunities for Case Management services.
4. Serves as a liaison between the patient and providers (behavioral health, medical and dental)
5. Receives documentation from providers and follows up with patients regarding their treatment plan
6. Sets up and attends meetings with providers and patients as needed
7. Informs all parties involved in the services that are being used to meet the patient’s needs
8. Inform and educate the patient and family members involved in ongoing treatment plans for patients, and provide the patient with written information regarding their treatment plan and other available resources
9. Maintain complete and accurate records of each patient using EHR
10. Maintain patient confidentiality in treatment plans and reporting as appropriate. Understands and abides by HIPAA guidelines
11. Delivers behavioral health education services. Develops educational materials such as audiovisual aids, articles, brochures, fact sheets and public service announcements promoting behavioral health and SDOH topics
12. Collects and analyzes data from various sources to evaluate programs and determine the need for additional educational programs or communications
13. Develops curriculum for community education and offer in-service sessions for Family Health Centers staff and outside organizations
14. Works with community contacts to promote Whole Person Health (emphasis on behavioral health) programs, teaches individual and group classes, and work with groups to solve community health issues
15. May be asked to provide input on grant proposals and report on program progress
KNOWLEDGE, SKILLS & ABILITIES:
Experience working with patients who have co-occurring mental health, substance abuse, and physical health problems; familiarity with screening and assessment, differential diagnoses, evidence-based psychosocial treatments and psychopharmacology for common mental/substance use disorders
Experience with evidence-based counseling techniques (e.g., CBT or PST) and brief, structured counseling techniques (e.g., SBIRT, motivational interviewing, behavioral activation).
Willingness to work with underserved, transient populations.
Ability to work with Medicaid eligibility programs.
Ability to effectively document services in the patient record, using an Electronic Health Record (EHR) system.
Ability to facilitate group-based services for adults and teens within the patient population.
EDUCATION & EXPERIENCE:
Job duties require knowledge and training in the field of behavioral and mental health typically acquired through a formal Bachelor level degree program in Counseling, Social Studies, Social Work, or Psychology. Fluency in English/Spanish preferred.
ELIGIBILITY QUALIFICATIONS:
Bachelor’s degree in social work, psychology or counseling or equivalent experience required. Valid WA Driver’s license and reliable transportation is required for travel between the clinics.