Brooklyn ACT: License Clinician-Family Specialist

Overview Provides direct clinical services including assessment and treatment planning, supportive counseling and supportive therapy, advocacy and psychoeducation, and linkage to community agencies and services, as required.  Provides coordination of services between the varying providers for clients/members with complex psychiatric, substance use, and/or co-morbid medical conditions.  Ensures access and linkage to the full array of necessary physical and behavioral health services and other community-based services to address social determinants of health.

Works under general supervision.
• Utilizes approved assessments to identify clients/members needs and family needs; develops initial and ongoing clinical plan of care. Updates plan at specified intervals, and as needed based on changes in client/member condition or circumstances.

• Performs and maintains effective care management for assigned caseload of clients/members. Leads the care coordination for complex psychiatric clinical cases. Tracks and monitors progress; maintains detailed, accurate and timely progress notes and other documentation.

• Provides supportive counseling and/or supportive therapy as well as ongoing mental health services. Collaborates and refers to appropriate agencies as required. Addresses any client/member concerns to ensure satisfaction with overall services provided and uses motivational interviewing techniques to foster behavioral changes.

• Develops inventory of resources that meet the clients/members needs as identified in the assessment.

• Provides linkage, coordination with, referral to and follow-up with appropriate service providers and managed care plans.  Facilitates periodic case record reviews and case conferences with all providers serving the clients/members.

• Provides information and assistance through advocacy and education to clients/members and family on availability and eligibility of entitlements and community services. Arranges transportation and accompanies clients/members to appointments as necessary.

• Assists clients/members and/or families in the development of a sustainable network of community-based supports, utilizing identified strengths and tools designed to prevent future participant crises and/or reduce the negative impact if a crisis does occur.

• Participates in initial and ongoing trainings as necessary to maintain and enhance clinical and professional skills.

• Maintains updated case records in program EMR. Maintains case records in accordance with program policies/procedures, VNS Health standards and regulatory requirements.

• Participates and consults with team supervisor in case conferences, staff meetings, utilization review and discharge planning meetings to determine if client/member requires an alternate level of care or is appropriate for discharge.

• Participates in 24/7 on-call coverage schedule and performs on-call duties, as required.

• Acts as liaison with other community agencies.

• Provides short term counseling (coping skills, trauma informed, decision making) and Risk Health Assessment/Safety Planning.

• Collects and reports data, as required while adhering to productivity standards.

• Leads and participates in “Network Meetings” with client, client/ member’s personal support network and other team members using the Open Dialogue Model.

• For Wellness WeCare Program Only:

• Clinical Assessments:
Conducts biopsychosocial assessments and reassessments using approved tools.

• SSA Disability Evaluation:
Performs Social Security Administration sequential evaluation process for determining disabilities.

• Document Review:
Reviews medical and health-related documents and prior records.

• Functional Capacity Determination:
Identifies limitations and determines employability or vocational rehabilitation needs.

• Coordination for Assessments:
Works with physicians and evaluating clinicians for additional medical or mental health assessments.

• Reporting:
Prepares clinical assessment reports as required by HRA.

• Motivational Interviewing:
Uses techniques to gather complete information during assessments.

• Compliance:
Adheres to HRA policies and procedures; participates in team…