Case Manager - Adult Bridge

Family & Children's Services•Tulsa, OK

5d•$55,000

About The Position

CCBHC is an integrated community behavioral health model of care intended to provide integrated, evidence-based, trauma-informed, recovery-oriented and person-and-family-centered care. The CCBHC offers the full array of CCBHC-required mental health, substance use disorder (SUD) and primary care screening services. The Care Coordinator will work in partnership with others as part of a structured inter-disciplinary team, within in a Certified Community Behavioral Health Center (CCBHC) model to coordinate care across the spectrum of health services, including access to high-quality physical (both acute and chronic) and behavioral health care as well as social services, housing, educational systems, and employment opportunities as necessary to facilitate wellness and recovery of the whole person. Care is provided in a culturally sensitive way and is delivered to an adult population who carry a serious mental illness, substance abuse, co-occurring and/or medically co-morbid diagnosis. Bridge Teams provide intensive, community-based services to individuals with severe mental illness. Clients served by Bridge Teams are transitioning from a recent psychiatric hospital discharge to outpatient services. Clients often have complex mental health needs, including acute psychosis, histories of trauma, and co-occurring substance use disorders. The primary function of Bridge Teams is to help reduce unnecessary hospitalizations and incarcerations, by providing individuals the resources essential to thrive and maintain independence in their natural environment.

Requirements

Requires Bachelor’s degree in social work or equivalent education.
Must obtain Case Management II Certification and Behavioral Health Wellness Coach certification upon hire.
Must possess Driver License and use personal automobile for local travel.
Must transport clients in personal automobile.

Nice To Haves

ODMHSAS CMII certification preferred.

Responsibilities

Attend and participate in daily organizational meetings and treatment team meetings with multi-disciplinary team to utilize a team based care approach when working with clients.
Document client progress to maintain a permanent record of client activity according to established methods and procedures.
Demonstrate understanding of various best-practice treatment models to work with individuals with Severe Mental Illness, Co-occurring disorders, and trauma.
Understand the wrap-around focus of CCBHC services, assisting clients in multiple life areas through multi-disciplinary teamwork and community referral.
Obtain and maintain professional licenses and certifications required for the position through attending required trainings, tracking CEU’s, and submitting renewals in a timely manner.
Be familiar with CCBHC standards, understand the history, philosophy, structure and purpose of CCBHC and demonstrate fidelity to the model.
Effectively complete and submit all clinical documentation with established agency timelines.
Coordinate care across the spectrum of health service, including access to high-quality physical (both acute and chronic) and behavioral health care.
Include the Consumer and family members in comprehensive treatment planning. With the adult consumer’s consent, encourage participation of family members and other designated persons in treatment planning and care.
Schedule, coordinate, facilitate daily/weekly treatment team.
Participate in daily/weekly treatment teams. (daily huddles)
Streamline plans of care across the Care Team.
Coordinate care with external health care providers such as pharmacies, PCPs, FQHCs, and DCOs, as well as with behavioral health referrals. Assist consumers and their families with obtaining and keeping referral appointments to outside providers.
Participate in initial treatment plans, strengths and culture preferences, and intakes as needed. Update and modify wrap plans as needed.
Provide individual, family, and/or group services that include screening, coordinating, planning, advocacy, linkage, referral, education, crisis intervention, resource acquisition, and monitoring in a culturally sensitive way.
Track consumers’ admissions and discharges from psychiatric & medical hospitalizations.
Participate in hospital and emergency department discharge processes to transition consumers to a safe community setting according to CCBHC protocols. Ensure timely transfer of medical records, prescriptions, and active follow-up.
Provide high intensity case management and care coordination services to clients following a post psychiatric hospitalization discharge.
Complete data surveys on clients.
Monitor individual health status and service use to determine adherence to or variance from treatment guidelines.
Develop and maintain housing resources for clients experiencing homelessness, including application processes and requirements, document submission, disability application process and submission. May also include outreach to clients in the community.