Consistently provide quality, recovery-focused, and person-centered integrated care to program participants in accordance with program philosophy, goals, objectives, policies, and processes.

Practice motivational conversation strategies and techniques throughout the assessment, individual program planning, and service delivery process, and actively promote and facilitate client self-determination.

Complete and record, in a highly accurate and timely manner, all required ongoing assessments and documentation applicable to services provided.

Develop, revise, and coordinate a plan of care and services that meets the client’s needs through collaboration with the person served, the behavioral health team, and team members from various organizations.

Facilitate the assessment of the client and involved family’s unmet health and social needs; educate about relevant community resources and facilitate/coordinate, close the loop on referrals, to such resources; serve as the client and family member’s contact point, advocate and informational resource.

Actively assist and promote client development and utilization of the Safety/Crisis Plan and wellness self-management goals

Facilitate client access to appropriate medical and specialty providers and ensure connections are made based on client needs.

Assist individuals in making and remembering appointments for acute, preventative, and follow-up care, and keeping scheduled appointments for services.

Actively foster health literacy knowledge and skills, and assist persons served in effective communication and self-advocacy with primary and behavioral health providers.

Maintain knowledge and comply with regulatory and third party payers’ procedures, including notification requirements and criteria, authorization and registration requirements, and documentation requirements.

Assist persons served in accessing and utilizing available transportation services including bus services

Facilitate and coordinate active and positive transition planning and discharge processes, and the delivery of follow-up services and supports for individuals leaving the program.

Demonstrated knowledge and skills in mental health rehabilitation and recovery principles and behavior intervention/management practices on direct service level.

Demonstrated knowledge of characteristics and needs of persons with a mental illness, including persons with co-morbid medical conditions.

Demonstrated knowledge of available behavioral health services, social services, and other community resources and basic case management principles.

Ability to maintain effective working relationships with individuals of diverse backgrounds including persons with mental illness, behavioral health and physical healthcare professionals, family members, social service providers, and public at large.

Ability to connect, communicate, and effectively work with people from diverse cultural, ethnic, socio-economic, educational, and professional backgrounds; and ability to maintain effective working relationships with diverse individuals and groups.

#INDEED