Job Opening: Community Transition Partner

NOW HIRING: Community Transition Partner –

Summary of Position: 

Engage individuals who are transitioning from inpatient facilities to the community by assisting them in implementing their discharge plan and ensuring that all services and supports that are necessary for a successful return to the community are in place. Establish positive, effective, and professional relationships with person served, families, colleagues and other components of the AHCCCS, Maricopa County Regional Behavioral Health Authority and other stakeholders. Implement quality supports and services which promote person-centered planning and clinically appropriate practices including the following principles for serving individuals enrolled in the Behavioral Health System, including the utilization of Evidenced Based Practices (EBP) as directed. 

Essential Functions:

Conducts assessments, determines eligibility, and develops individualized service plans;

Support participants who are transitioning from inpatient psychiatric settings into the community by providing peer mentorship, advocacy and education;

Educates and utilizes community resources;

Provides case management services in conjunction with community partners;

Assist in advocating, implementing and coordinating a proactive array of comprehensive, individualized supports and services for program participants and performs administrative work in support of the program.

Familiar with the Critical Time Intervention model of needs based case management.

Understands the principles and practices of oversite/supervision and ensuring all staff meet requirements;

Complete enrollments, Score cards;

Deliver services and supports as defined in Protocols developed for the Community Transition Program;

Intensive Engagement Protocol;

Intensive collaborative discharge planning with in-patient and outpatient teams.

Two face-to-face encounters in the first week and one face-to-face in the second week, or approximately 3 to 4 in-patient face-to-face encounters.

Two phone contacts each with in-patient and outpatient team weekly.

First 30 to 60 days in the community: minimum of two face-to-face contacts weekly (or outreach attempts), minimum of two weekly phone contacts with participant, minimum of one phone contact with PNO team

Next 30 to 60 days in the community: one weekly face-to-face contact, two weekly phone contacts with participant, one weekly phone contact with outpatient team

Standard Engagement Protocol:

Routine collaborative discharge planning with in-patient and PNO teams.

First 30 days in the community: two face-to-face contacts weekly, one phone contact with participant weekly, one phone contact with PNO team

Second 30 days in the community: one weekly face-to-face contact, two weekly phone contacts with participant, one weekly phone contact with outpatient team

Last 30 days in the community: bi-weekly face-to-face contacts, bi-weekly phone contact with outpatient team

Identify any deviations from the protocols that are necessary due to individual circumstances;

Develop Individualized Service Plans for each participant using the comprehensive assessment;

Collect all necessary documentation needed to support the individual’s goals and maintain a comprehensive Medical Record;

Provide case management services including, but not limited to: providing appropriate resources, education and tools, to assist participants in achieving their goals;

Making referrals for services;

Collaborate with other departments and agency programs, Community Resources, Clinical to maximize participant outcomes, program goals, and agency mission to ensure Coordination of Care;

Document and maintain up-to-date information on services provided to individuals Medical Record;

Prepare and submit weekly/monthly program reports as directed;

Completes and provides Clinical Oversite/Supervision as determined by licensure, CARF and Marc’s

Policies;

Performs a variety of Covered Services that have encounter value.

Other duties as assigned.

Essential Mental Functions:

  • Problem solving
  • Adapting to changing environments
  • Visual monitoring of environments
  • Ability to assess behavioral situations and utilize crisis management as applicable
  • Attentive
  • Professional
  • Ability to utilize crisis management and trauma informed care
  • Instructing and training of others
  • Ability to work with diverse personalities
  • Ability to solve mathematical problems (adding, subtracting, multiplying and division);
  • Proficient with technology
  • Maintains a Person Centered approach
  • Building and maintaining positive and effective relations with all stakeholders

 

Physical Requirements:

Must maintain body equilibrium as well as finger dexterity, but not limited to the following:

  • Walking
  • Visual acuity
  • Standing/Sitting
  • Driving
  • Bending/Twisting/ Turning
  • Reading/Writing/Typing
  • Complete annual TB Test

 

Equipment Used:

  • Personal Vehicles/Marc vehicles (approved drivers)
  • Computers (including e-mail, NextGen, Kronos and other systems as required)
  • Telephones, cell phones, and fax machine.

 

QUALIFICATIONS AND EXPERIENCE

  • Must be at least 21 years old. Requires any combination of training, education, and experience listed below:
  • Has a master’s degree or bachelor’s degree in a field related to behavioral health;
  • Is a registered nurse;
  • Is a physician assistant who is not working as a medical practitioner;
  • Has a bachelor’s degree and at least one year of full-time behavioral health work experience;
  • Has an associate degree and at least two years of full-time behavioral health work experience;
  • Has a high school diploma or high school equivalency diploma and:
  • 18 credit hours of post-high school education in a field related to behavioral health completed no more than four years before the date the individual begins providing behavioral health services and two years of full-time behavioral health work experience, or four years of full-time behavioral health work experience; or is licensed as a practical nurse, according to A.R.S. Title 32, Chapter 15, with at least two years of full-time behavioral health work experience;
  • Credentialed as a BHT as determined by Marc’s policies.
  • Certification of Peer Support Specialist as recognized by the state of AZ;
  • Satisfactory work history as determined by the Human Resources.

 

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Marc Community Resources, Inc. is an Equal Opportunity Employer – All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, disability status, protected veteran status, or any other characteristics protected by law.