Conduct outreach activities through various methods and engage individuals with chronic medical conditions, mental health issues, and/or substance use disorders, often o-occurring.
Essential Accountabilities:
- Conduct outreach activities through various methods and engage individuals with chronic medical conditions, mental health issues, and/or substance use disorders, often co-occurring.
- Conduct initial and ongoing comprehensive assessments to determine strengths and identified needs.
- Prepare and revise care plans to reflect client needs and personal goals with a focus on maintaining health and wellness.
- Maintain contact with clients at least monthly, providing telephonic as well as face to face outreach, engagement, and comprehensive service planning in the field.
- Advocate for and support clients to ensure access to resources necessary to support wellness/self-management and decrease frequency of emergency room visits and inpatient hospital admissions.
- Monitor and coordinate all care for clients, including access and maintenance of medical insurance, linkage to treatment providers and community resources.
- Collaborate with community providers as part of a multi-disciplinary team to ensure goal-directed care planning.
- Conduct crisis intervention when needed and follow up accordingly.
- Maintain detailed, timely, and accurate record keeping in an electronic medical record. Coordinate with supervisor, office manager, and health home outreach team in a timely manner to ensure accurate caseload status (including enrollments, closures, and screen outs).
- Complete all required monthly documentation as required to ensure continuity of engaged clients’ medical insurance and to ensure appropriate and accurate billing.
- Work as part of a care management team, attend and participate in weekly team meetings to provide feedback and share resource information relating to client needs, issues, and concerns.
- Be responsible for reporting/coordinating daily office and field schedules with other members of the team and supervisor, as well as documenting schedule for the office manager.
- Offer resources and serve as a consultant to all team members on medical/psychosocial/substance use issues as well as social service needs.
- Attend periodic trainings to enhance skill level and learn about wellness self-management and best practice skills.
- Participate in weekly individual supervision to address concerns/issues and improve skill development.
- Be responsible for agency vehicles, including upkeep, documentation, and gas card when assigned.
- Be responsible for agency cell phone, laptop, and associated items.
- Follow program guidelines as outlined in the personnel manual.
- Report to the program administration any issues and/or concerns on a regular/as needed basis while working in the field. I acknowledge that the above job description has been reviewed with me and that I am able to perform the necessary functions of the above job description.
