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The Targeted Case Manager may function at the initial entry point of the care continuum within the Certified Community Behavioral Health Center (CCBHC) by providing outreach, case management, and information about the health care system in general and at care transition points between health care agencies (i.e. emergency department/inpatient unit to community services). Ongoing care includes providing health education/health promotion in partnership with other members of the Interdisciplinary Team. Integrated behavioral health care is the systematic coordination of physical and behavioral health care.

ESSENTIAL FUNCTIONS:

• Conduct assessments of participants with their guardian and/or natural supports for physical health, mental health, and social service needs.
• Provide information on the importance, availability and appropriate use of primary and emergency care. Assist in the exploration of less restrictive alternatives to hospitalization.
• Assist the integrated team with the coordination and monitoring to ensure that the Individual Treatment Plan (ITP) is effectively implemented and adequately addresses the needs of the person.
• Determine appropriate level of care using evidenced based screening tools.
• Provides primary care coordination activities as a part of the CCBHC monitoring and follow-up, including adapting supports, treatment plans, crisis plans, and/or Psychiatric Advance Directives as needed to respond to changes in the needs and preferences of individuals being served.
• Refer participants to other services and resources including, but not limited to, other behavioral health and/or medical services, housing, food, clothing and other basic needs.
• Be available to provide in person coverage and supports to the CCBHC walk-in center.
• Participate in the development of a wellness plan for self-management of chronic conditions and for coordinating services; provide assistance to Integrated Behavioral Health patients to help them achieve their wellness goals through a variety of activities such as accompanying them to appointments or supporting them in these activities as needed.
• Assist in obtaining or maintaining health insurance; assist them in applying for health insurance through application assistance and follow-up to ensure they obtain any insurance for which they qualify.
• Assist in determining whether participants have or are eligible for housing; assist them in applying for housing through applications, available resources, and assist in the follow-up to ensure they qualify.
• Participate in crisis intervention, resolution and follow-up services.
• Proficient in electronic health records (EHR). Document services by entering participant data into (EHR), complying with all organization, state, and federal documentation requirements.
• Facilitate active and timely communication among the members of the CCBHC team.
• Facilitate transportation to and from medical appointments and other community integration activities as needed.

EDUCATION:

• Successfully complete an orientation and training program in wellness case management/advocacy that includes support for assisting patients with making life changes to help them self-manage and/or improve their chronic condition(s).
• Bachelor's degree (B. A.) from four-year college or university in Human Services in psychology, mental health and human services, behavioral health, behavioral sciences, social work, human development, special education, counseling, rehabilitation, sociology, nursing or closely related field, preferred, but not required. 

CERTIFICATES, LICENSES, REGISTRATIONS:

• Maintain a valid state driver’s license.
• MHRTc Certified or eligible.

EXPERIENCE:

• Experience working in or with a primary care clinic with medical staff strongly encouraged.
• Persons with lived experience in the Mental Health and/or Substance Abuse system are encouraged to apply.

KNOWLEDGE & SKILLS:

• Knowledge in some or all of the following areas: Child development, family systems, special education, mental health, developmental delays, juvenile justice system.
• Skills in being well organized, able to independently prioritize workload, and having excellent interpersonal skills.