Key responsibilities

• Assessment and planning: 

Evaluate the client’s needs and develop an individualized discharge plan that addresses their specific treatment goals and social environment situation. 

• Coordination: 

Connect with community resources, such as mental health providers, primary care, MAT, and support groups, to arrange services and facilitate a smooth transition to next levels of care. 

• Education: 

Educate the client, and their family if involved, about their recovery options, medication, warning signs of return to use, the importance of keeping their appointments, and how to use coping skills in their daily life. 

• Advocacy: 

Act as an advocate for the client, working with the treatment team to ensure their needs are met and that they are prepared for success after transition to the next level of care. 

• Documentation: 

Maintain accurate and timely records of all activities related to the discharge/transition planning process and plan.

• Communication:

Work closely with the continuum management unit to ensure efficient and timely client transition in order to provide real time information for census monitoring across the continuum of care.  Ongoing inteaction with staff from different levels of care to ensure warm handoffs for clients.

Knowledge Of:

• Community resources such as public assistance programs, mental health providers, housing programs, sober living environments, physical health, vision and dental referrals, legal assistance providers, and cultural and community social supports
• Techniques for dealing with a variety of individuals from various socio-economic, ethnic, and cultural backgrounds
• Office procedures, methods, and equipment including computers and applicable software applications such as word processing, spreadsheets, databases, and other specialized applications related to area of assignment
• Basic social and psychological needs, problems, attitudes, and behavior patterns of individuals with substance use and/or co-occurring disorders
• ASAM assessment, ASAM patient placement matrix, and evidence based practices for working with individuals with substance use disorders, for example, motivational interviewing, cognitive behavioral techniques, and trauma-informed care

Ability To: 

• Establish and maintain effective working relationships with clients, their families, and with professional, paraprofessional, and support staff within the agency and pubic facing partners
• Work effectively as a member of a multi-disciplinary team
• Communicate clearly and effectively both verbally and in writing
• Respond appropriately in crisis situations and ability to de-escalate clients when needed
• Work effectively in stressful, emotional, and confrontational situations requiring good judgment, self-control, and motivating people
• Document medical records accurately and thoroughly according to regulatory standards
• Research, identify, and use community resources to assist clients with services that align with their individual needs, such as outpatient treatment options or applying for public assistance programs
• Identify available financial resources and prepare calculations for recommended placement
• Read, write and speak English at a level necessary for satisfactory job performance
• Ability to protect client privacy, confidentiality, and adhere to security standards and regulatory guidelines
• Ability to maintain professional boundaries in the clinical and therapeutic relationship with clients

Requirements:

Minimally a RADT or CADAAC I, II, or III current certification.  Minimum 2 year experience in working with substance using clients and clients with co-occurring needs.  Minimum 2 year experience in care coordination.  Preferred, established professional ties in the community for public facing communication and ease of client referrals.