Duties/ Responsibilities (these duties are a general summary and not all inclusive):

• Utilizing a collaborative documentation approach, completes a comprehensive social determinants of health assessment which is maintained in the patient’s electronic health record (EHR) within five days of initial contact with the patient according to established center’s Quality Improvement Plan (QIP) workflow.
• Coordinates the development of individual service plans (ISP) for patients on caseload. Ensures that the primary care provider team inputs are coordinated with ISP development according to established Texas Department of State Health Services (DSHS) Clinical Management Behavioral Health System (CMBHS) criteria and timelines.
• Provides clinical case management for cases assigned to ensure timely and effective delivery and management of services identified on the ISP.
• Provides patients with self-management skills and educational information needed so they can be full participants in their own treatment and recovery.
• Provides highly skilled clinical social work services to patients and their families, utilizing a wide array of intervention modalities including Cognitive Behavioral Treatment (CBT), Motivational Interviewing, individual, group, and family therapy for the purposes of changing maladaptive behavior, enhancing client capacity to cope with symptoms of mental health challenges and / or substance abuse, completing a relapse prevention plan with patients who are in remission, and improving communication and interactions between the patient and his or her primary support system.
• Coordinates via a Social Determinates of Health (SDOH) Lens, pre-discharge arrangements and communications with primary care providers, completes oral and written referrals in an accurate and timely manner to aftercare services for community-based services, psychosocial rehabilitation services, specialized outpatient therapy and medication, residential services, substance abuse services, and other agencies as determined by patient need.
• Provides highly skilled psychoeducation services to patients, their families, and other service providers to increase understanding of mental health challenges, substance abuse, legal factors, and other issues as determined by patient need to enhance patient and family knowledge and utilization of rehabilitation processes and resources.
• Provides brief, solution focused counseling and intervention for patients who need mental health services.
• Documents interventions in progress notes, group treatment notes, and patient and family education form according to CMBHS established standards. Utilizes goal orientated focus for interventions and documentation.
• Maintains knowledge of current developments in statutes, case law, and departmental / agency regulations in the fields of social work, and mental health. Utilizes this knowledge in providing direct services and in collaboration with Center’s primary care providers.
• Consults with patient and primary care provider about behavioral treatment options and preferences; coordinates initiation of ISP, identifies possible barriers to treatment and supports development of solutions to barriers.
• Support patient service flow through the maintenance of collaborative processes with various NTACHC staff to enhance the “patient experience”.
• Monitors patients closely (in-person or by phone) to administer follow up assessments and facilitate engagement in treatment.
• Works with primary care clinical team and leadership in ensuring patient flow for behavioral health services, including scheduling of patients.
• Works, where indicated, to effect behavioral changes in patients with, or at risk for, physical disorders and helps them make healthier lifestyle choices.
• Gives primary care providers timely feedback about the patients ’s care, treatment recommendations, and progress via verbal feedback and documentation in the patients record
• Provides social work supervision to assigned graduate students. Assigns, monitors, and evaluates work for assigned social work intern and unlicensed social work staff.
• Provides leadership in social work department and center wide performance improvement / quality improvement activities.

Performs other duties as assigned by the Director of Behavioral Health consistent with professional standards, the goals, and objectives of the program and with the clinical practice policies of NTACHC.