Care Team Specialist Nebraska CCBHC

At Heartland Family Service we are committed to building a culture that is trauma informed and values and celebrates diversity and inclusion. We believe this allows for better service delivery and innovation as it encourages our employees to bring various experiences and uniqueness to the workplace.

Trauma Informed Care is an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. Trauma Informed Care also acknowledges the effects ofworking with trauma survivors on our workforce and seeks to build collaborative and supportive working environments and relationships.

If you believe in our mission of creating healthy families and communities and like a fast pace collaborative and team-oriented environment then Heartland Family Service is the agency for you.

SUMMARY DESCRIPTION OF WORK

The Care Team Specialist (CTS) is a care coordination role within the Certified Community Behavioral Health Clinic (CCBHC) model responsible for supporting timely access engagement and continuity of care for individuals receiving mental health and/or substance use services. The CTS serves as a central coordination point to identify care team members address barriers to service access and facilitate communication across medical behavioral health substance use and community support systems.

This role includes direct client engagement to support care coordination and continuity. The CTS focuses on maintaining system-level alignment monitoring engagement identifying gaps in care and connecting clients to the appropriate level of ongoing support.

Compensation: between $19.74 and $23.54 per hour (wage is based upon total years of relevant experience).

Work Schedule:37.5 hours per week

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MINIMUM QUALIFICATIONS

• Bachelors degree in social work psychology sociology human services or related field (or comparable experience)
• One (1) year experience in health behavioral health or human services preferred
• Demonstrated ability to engage clients and communicate effectively with providers
• Basic computer and documentation skills
• Strong communication skills with providers and community partners
• Ability to work within a multidisciplinary team-based care model

Essential Duties and Responsibilities

• Serve as an initial point of contact to build rapport and assess client needs related to access coordination and engagement in services.
• Identify existing care team members including medical behavioral health substance use social service and natural supports and when such supports are not yet in place identify and facilitate connections to appropriate resources and care team members.
• *Monitor client engagement and service connectivity including follow-up on missed appointments transitions of care and emerging barriers.
• *Coordinate care during transitions including hospital discharge crisis stabilization or changes in provider level of care.
• Ensure completion of required CCBHC-aligned assessments and when appropriate and within scope administer designated screening tools to support access and coordination.
• Contribute (LEAD) the development and updating of individualized care coordination plans in collaboration with the client and providers identifying strengths needs goals and service alignment. (Does not replace clinical treatment planning.)
• Assist clients with referrals releases of information and warm handoffs to appropriate services.
• Facilitate communication among providers internal teams and support networks to promote continuity and shared understanding of care goals.
• Support timely access to services by coordinating referrals releases of information and warm handoffs.
• Identify gaps in services or access and advocate for connection to appropriate community resources.
• Coordinate case review conferences or care team communication when appropriate.
• Complete and maintain accurate timely documentation in accordance with agency and state standards that are audit ready.
• Maintain episodic purpose-driven contact with clients to confirm care connections.
• Identify when client needs exceed the CTS scope and escalate to targeted case management or other appropriate services. May provide short-term crisis-responsive case management while facilitating referral and transition to other appropriate services.
• Build and work within a multidisciplinary team utilizing team expertise appropriately.
• Maintain professional relationships with community providers and service partners.
• Identify gaps in care access or coordination and facilitate connection to appropriate services and care team members to advocate for client needs where necessary.
• Support agency efforts to build community connections that enhance access to care.
• Some community-based coordination and provider communication may be required.
• Agrees to always display a courteous and caring attitude to the clientele volunteers and visitors of the Agency.
• Cooperates and collaborates with program area staff volunteers and other Agency staff.
• Is dependable and punctual regarding scheduling and attendance.
• Abides by all specific program and Agency procedures policies and requirements.
• Develops personal and program related skills through participation in internal and external training opportunities including printed material and audio and/or visual media.
• Creates maintains and shares an appropriate and dynamic self-care plan.
• Essential functions are performed on-site or in designated workspaces. Some work may be conducted in clients home or out in the community.
• Performs other program related duties as assigned.

Required Experience:

IC