The Clinical Community Liaison provides person-centered, community-based clinical care management services for individuals referred to and participants in Community Transitions programs. The goal is to ensure that comprehensive, coordinated, easily accessible, culturally informed, trauma informed, and integrated services are available for people in the community; and to minimize the risk of readmissions to hospitals, emergency departments, withdrawal management, Colorado Crisis Services and arrest; and to ensure an individual’s stability in the community. The Clinical Community Liaison will support daytime and after-hours communication with providers to discuss appropriate referrals, creating client charts in the electronic health record and facilitating client communication for a warm hand-off at the time of referral. The Clinical Community Liaison will provide supports to individuals with serious and persistent mental illness and substance use disorders, including responding to after-hours behavioral health needs to support individuals' engagement in treatment, providing clinical guidance to connect to the appropriate level of care, and supporting the coordination of behavioral health treatment services.
- Provides after-hours coverage for the Community Transitions program including evening and weekend shifts.
- Manages referrals and intakes: answers all incoming calls, responds timely to all communication, completes data entry of intake and referrals into database daily, uses clinical knowledge to determine program eligibility, along with referral tracking, and basic audits of the database.
- Responds to community partners with referral questions including determining eligibility, communicating status on the wait list, and ensuring necessary documentation is received with the referral form.
- Follows up with referral sources to complete intake assessment and attend to interim needs for support prior to assignment to a Clinical Care Manager.
- Perform professional interpretation and analysis of clinical data and assessments to formulate waitlist prioritization to ensure clients are assigned based on contract priority and need.
- Provide interim and after-hours care management for individuals to ensure successful maintenance of community-based living and treatment after transitioning from state hospitals, acute treatment centers, crisis services facilities, withdrawal management facilities, criminal justice settings, or other higher levels of care. This includes supporting individuals in the community and in the hospital or through virtual means as needed to ensure continuity of community supports for successful transition.
- Ability to independently clinically assess an individual’s needs, including understanding mental health symptoms, coordinating behavioral health services and referring to crisis services as appropriate. Ability to utilize clinical skills such as motivational interviewing, brief interventions and de-escalation techniques.
- Assist in accessing services and coordinating care while ensuring individuals have all the resources required for daily living (such as: food, housing, therapies, and transportation).
- Assist individuals, families, and community partners with understanding services provided by Community Transitions. This may include coordination with providers such as community mental health centers, primary care, case management, Assertive Community Treatment teams, Regional Accountable Entities, and others.
- Advocate for the best interest of the individual by working with providers to resolve conflict as it relates to the individual’s referral to Community Transitions.
- Collaborate with Peer Support Specialists to communicate needs related to care plans, service coordination, and treatment provider communication.
- Educate Alternative Care Facility and Skilled Nursing Facility staff about successful interventions and care strategies for individuals, as needed to increase individual’s success in maintaining the least restrictive setting that can meet their needs.
- Assist in linking with CMHC or other identified provider to enroll the client in the necessary and required behavioral health services.
- Identify and report to supervisor any team activities and issues that influence the delivery of services under the contract.
- Complete all documentation as required according to contractual, organizational, and legal requirements.
- Actively participate in supervision and case consultation.
- Performs other duties as assigned.
Knowledge, Skills and Abilities
- Knowledge related to clinical diagnoses, including serious and persistent mental illness and substance use disorders, and ability to interact effectively with individuals experiencing these disorders.
- Knowledge of qualifying psychiatric hospitals, withdrawal management facilities and emergency departments in the state of Colorado.
- Ability to independently assess eligibility criteria for Community Transitions programs.
- Knowledge of general standards of practice in behavioral health settings and ability to communicate effectively with psychiatrists and other behavioral health clinicians.
- Ability to work independently in the community and from a home office, and to travel to the RMHS office as required.
- Ability to work hours outside of regular business hours, including evenings and weekends, as determined by the needs of the program.
- Strong communication skills with individuals served in the program, team members, colleagues, and community partners.
- Ability to independently assess crisis situations and connect individuals to appropriate resources including the Colorado Crisis Line or emergency services.
- Knowledge of community resources related to the behavioral health needs of the individuals in the programs.
- Ability to self-manage time, priorities, and resources to achieve program goals.
- Familiarity with DSM V and ICD-10, behavioral health symptoms, and general medication side-effects.
- Comfortable utilizing de-escalation strategies and Motivational Interviewing as needed
- Maintain strict confidentiality and fulfil the requirements of HIPAA and other relevant rules and regulations.
- Maintain appropriate boundaries and professional demeanor.
- Track client spending to a budget per program requirements.
- Document timely utilizing standards of practice for the profession.
- Work independently with minimal supervision.
- Strong data entry skill and attention to detail with the ability to enter data timely and accurately per program requirements.
- Understand and use a person-centered, culturally informed and trauma informed principles.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Actively communicate with individuals, caregivers, families, stakeholders, advocates and providers.
- Ability to meet/work with staff, stakeholders or individuals in a variety of settings.
- Attends staff, team and department meetings.
- Attends in-services, staffing and other meetings with supervisor’s approval. May be appointed to committees.
- Participates in agency and community planning and education.
- Develops and maintains records, plans and reports.
- Lift and/or carry 20 lbs.
- Sit, stand and walk for reasonable periods of time.
- Maintains prompt and regular attendance.
- Performs related work as assigned.
- Ability to drive personal or company vehicle.