Summary:
Overall Responsibilities include a licensed therapist with superb assessment, evaluation, diagnostic and synthesis skills. Client engagement and ability to establish a therapeutic relationship are essential. Motivational interviewing skills is a plus. Must be able to provide timely and accurate comprehensive clinical assessments (CCA), with a knowledge of NC clinical coverage policy definitions, level of care tools (i.e., LOCUS and ASAM), and a commitment to engaging the client in the right level of care immediately. The assessment, evaluation and diagnostic therapist is a skilled professional that drives the overall direction of care, allowing for an excellent person center planning process to occur. A strong advocate for the client assuring they receive timely and proper care, based on diagnostic assessment results. Represent the purpose, vision and mission of Southeastern Integrated Care, Inc.
Essential Duties and Responsibilities:
- Conducting Assessments -Comprehensive Clinical Assessment (CCA)/ Diagnostic Assessments and Person-Centered Planning in accordance with NC Clinical Coverage Policy No:8A-5, DLA-
20 Guidelines and NC APSM 45-2 Records Management and Documentation Manual
- CCA/ Diagnostic Assessments must include ALL the following elements:
- description of the presenting problems, including source of distress, precipitating events, and associated problems or symptoms;
- chronological general health, past trauma history and behavioral health history (including both mental health and substance use including tobacco use) of the beneficiary’s symptoms, treatment, and treatment response;
- current medications for medical, psychiatric, and substance use disorder treatment. Identify past medications that were ineffective or caused significant side effects or adverse reactions.;
- a review of biological, psychological, familial, social, developmental and environmental dimensions to identify strengths, needs, and risks in each area;
- evidence of beneficiary and legally responsible person’s (if applicable) participation in the assessment;
- analysis and interpretation of the assessment information with an appropriate case formulation including determination of American Society of Addiction Medicine (ASAM) level of care when a substance use disorder is present; or LOCUS (level of care utilization system for Mental Health diagnosis)
- diagnosis using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), or any subsequent editions of this reference material including mental health, substance use disorders, or intellectual or developmental disabilities, as well as physical health conditions and functional impairment;
- recommendations for additional assessments, services, supports or treatment based on the results of the assessment;
- the diagnostic assessment must be signed and dated by the licensed professionals completing the assessment; and
- evidence of an interdisciplinary team service note that documents the team’s review and discussion of the assessment. The involvement of the team in the delivery of the service is very important and is documented in the team note. Particular emphasis is made on the involvement and participation of all members of the team in the formulation of the diagnoses and treatment recommendations.
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Documentation must be : Accurate — describing the facts as observed or reported; Timely — recording significant information at the time of the event, to avoid inaccurate or incomplete information; Objective — recording facts and avoiding drawing conclusions. Professional opinion must be phrased to clearly indicate that it is the view of the recorder; Specific, concise, and descriptive — recording in detail rather than in general terms, being brief and meaningful without sacrificing essential facts, and thoroughly describing observation and other pertinent information; Consistent — explaining any contradictions and giving the reasons for the contradictions; Comprehensive, logical, and reflective of thought processes — recording significant information relative to an individual's condition and course of treatment or rehabilitation. Document pertinent findings, services rendered, changes in the beneficiary's condition, and response to treatment or rehabilitation, as appropriate. Include justification for initial services as well as continued treatment or rehabilitation needs. Document reasons for any atypical treatment or rehabilitation utilized. Clear — recording meaningful information, particularly for other staff involved in the care or treatment of the individual. Write in nontechnical terms to the extent possible. Person-Centered – Use person first language when describing individuals, behavioral characteristics, treatment, events, and all other information that produces a picture of this person.
- Collaboration and partnership with community agencies
- Previous work providing in-home or community-based therapy services
- Provide services based on the principles of wellness self-management, personal recovery, natural supports, coping skills, and self-advocacy skills, and development of independent living skills
- Assist clients with self-determination and decision-making.
- Model recovery values, attitudes, beliefs, and personal action to encourage wellness.
- Teach and promote self-advocacy and empower clients to use their legal rights.
- Respect and protect client confidence and patient confidentiality by keeping all sensitive and client information private.
- Other duties as assigned
Supervisory Responsibilities:
This position does not oversee staff.
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education/Experience Master’s degree in clinical or counseling Psychology, Social Work, or a related subject area required, or bachelor’s degree with requisite experience in a similar field and meets QP definition. Must possess a NC state clinical license or provisional license (i.e., PHD, LCSW, LPC, LCMHC, LCAS)
Required Skills/Abilities - Excellent engagement skills
- Excellent communications skills
- Excellent synthesis of information from the client, former records, and collateral skills
- Able to work within EMR and familiar with adjunct diagnostic assessment tools.
- Excellent Diagnostic Skills
- Excellent Level of Care skills
- Excellent working knowledge of NC clinical coverage policies for behavioral health
- Excellent documentation skills
- Able to work in a fast-paced environment both independently and collaboratively with team members.
Certificates, Licenses, Registrations The ideal team member will have the below training or will receive within the first 90 days of hire.
- CPR, first aid, NCI, and/or role-related certification OR within 3 months of hire.
- NC state license or provisional license (i.e., PHD, LCSW, LPC, LCMHC, LCAS)
Work Environment:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The work is typically performed in a community setting with a moderate noise level.
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Must be able to assist beneficiaries in and out of the vehicle as needed.
- Must be able to drive and operate a vehicle safely and adhere to all applicable state and traffic laws.
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