Integrated Care Team. Works collaboratively with the integrated care team to engage, educate, communicate, and coordinate care with service participants, their family, behavioral health, medical and dental providers, community resources and others in ensuring that all services prescribed in the Integrated Service Plan are implemented. Develops and maintains and manages the Integrated Service Plan (ISP) within required timeframes.

·         Adjusts the ISP and service delivery as needed based on progress/lack of progress in the specified health, wellness and behavioral health goals.

·         Provides assistance in maintaining, monitoring and modifying covered behavioral health and healthcare services and community resource needs;

·         Maintains the person’s comprehensive clinical record, including documentation of activities performed as part of the service delivery process (e.g., assessments, provision of services, coordination of care, discharge planning).

·         Coordinates and communicates with Clinical Coordinators, Integrated Care Coordinators, nursing and medical and psychiatric practitioners for individuals exhibiting urgent or emergent medical and/or psychiatric symptoms.

·         Participates in regular care team meetings and staffings and documents actions to modify service delivery based on progress, social determinants of health, health literacy, health care activation, current gaps in care, the Health Risk Assessment and level of self-management of chronic conditions.

·         Provides continuous screenings and evaluations of treatment effectiveness for service referrals, including counseling, residential and supportive services and community resources. Makes recommendations for initial and concurrent authorization of service referrals .Participates in and supports fidelity of integrated care practice, including training, performance measurement and enhanced communication protocols for Integrated Care teams.

·         Serves as the primary point of contact for the caseload, providing  direct   services including, but not limited to:

                                i.         Telephone or face to face interactions with a person, family or other involved party for the purpose of maintaining or enhancing a person’s functioning within PIR timeframes;

                              ii.         Assistance in finding necessary community resources other than covered services to meet basic needs;

                            iii.         Ensures referrals to and  provision of all covered services identified on the service plan within PIR timeframes; ensures continuity of care between levels of care and across multiple providers, services and supports;

·         Provides outreach, re-engagement and follow-up services including, but not limited to, crisis and missed appointments

·         Screens and assesses all persons on caseload for financial entitlements (AHCCCS, SSI/SSD etc.); completes AHCCCS applications on all members on caseload meeting criteria;

·         Provides or arranges for transportation  as appropriate and determined by the care team;

·         Ensures that transfers to out-of-area, out-of-state or to an Arizona Long Term Care System (ALTCS) contractor, are coordinated as applicable;

·         Assistance in maintaining and monitoring person’s court ordered treatment, i.e. COT appointment, court appointments, status reports, and tracking of IP hospital days, etc.

·         Collaborates with the person and his/her family or significant others to implement an effective service plan, explaining the available clinical options to the team, including the advantages and disadvantages of each option.

·         Pursues best practice outcomes for persons with mental illness including continuing education, employment, independent housing and community tenure.

·         Consistently meet organizational encounter and performance  goals , and follow  clinical documentation standards as defined by company policy,

·         Other duties as assigned.