Licensed Clinical Care Advisor Transition of Care (Region 3)

About the role

The Clinical Care Advisor Transition of Care is responsible for coordinating operations and workflows related to case management activities in support of specialty programs, such as Foster Care. Serves as a coach. Performs case management telephonically and/or by home visits within the scope of licensure. Manages overall healthcare costs for the designated population via integrated (physical health/behavioral health) case management and whole person health. Manages the most complex cases and provides support to Special Programs case managers.

Responsibilities

• Engage collaboratively with key stakeholders including families, foster parents, and service teams to craft and sustain individualized treatment plans.
• Facilitate effective transitions of care for children and families moving between treatment settings.
• Conducts assessments to identify individual needs. Develops comprehensive care plan to address objectives and goals as identified during assessment.
• Supports member access to appropriate quality and cost-effective care and modifies plan(s) as needed.
• Collaborates with internal and external resources to meet identified needs of the member in terms of integrated (physical and behavioral) whole person care.
• Captures social determinants of health to meet the needs of the member and incorporates that into care planning.
• Works closely with various state agencies.
• Maintains knowledge of the system of care philosophy; a spectrum of effective, community-based services and supports for those with or at risk for mental health or other challenges and their families, that is organized into a coordinated network.
• Builds meaningful partnerships with designated populations and their families, and addresses cultural and linguistic needs, in order to help them function better at home, in the community, and throughout life.
• Evaluates health needs and identifies applicable services and resources in conjunction with members and their families.
• Provides important information including patient education, medication reconciliation, and identification of community resources and assists with arrangement of follow-up care.

Requirements

• Requires MS/MA in social work, counseling, or a related behavioral health field or a degree in nursing and minimum of 3 years of clinical experience in social work counseling with broad range of experience with complex psychiatric and substance abuse or substance abuse disorder treatment; or any combination of education and experience, which would provide an equivalent background.
• Requires an active, current and valid license as an RN, LCSW (as applicable by state law and scope of practice), LMHC, LPC (as allowed by applicable state laws), LMFT, or Clinical Psychologist to practice as a health professional within the scope of licensure in applicable states or territory of the United States.

Preferred Skills, Capabilities, and Experiences

• Travels to worksite and other locations as necessary.
• Experience with transitions of care working in agencies or organizations serving children, youth and family involved in Department of Social Services and Juvenile Justice, with a deep understanding of the therapeutic residential and facility-based services within North Carolina, including the utilization of crisis and transition homes, Psychiatric Residential Treatment Facilities (PRTF), High Fidelity Wraparound and Assertive Community Treatment is strongly preferred.
• Experience working with transitional age youth and young adults preferred.
• Experience working with children, youth, and families who are being served by Local Departments of Social Services through Foster Care and Adoptive Assistance programs is strongly preferred.
• Knowledge of resources, supports, services and opportunities required for safe community living for populations receiving in-reach and transition services, including LTSS, Behavioral Health, therapeutic, and physical health services.
• Service delivery coordination, discharge planning or behavioral health experience in a managed care setting preferred.