POSITION SUMMARY 
Responsible for the Disease Management 3700 (DM 3700 CPS and SUD) program coordination. Provides outreach and case management services to persons diagnosed with a serious and persistent mental illness primarily those identified as DM 3700.  

ESSENTIAL DUTIES AND RESPONSIBILITIES
The essential functions include, but are not limited to the following:
• Provide outreach to engage consumers who have been identified as DM 3700 to participate in mental health/substance use treatment services.

• In conjunction with CPRP team, coordinate DM 3700 services including; reviewing DM 3700 reports and providing status updates to DBH as required. Responsible for reviewing and updating information in Care Manager, reviewing cyber access, and participating in the DM 3700 learning collaborative. 

• Provide additional outreach to individuals to participate in HCH services, and work in collaboration with Health Care Home team to provide assistance to participants regarding their overall physical health by using wellness coaching techniques.

• Work in conjunction with Healthcare Home services to ensure all DM 3700 consumers receive a Metabolic screening within 30 days of admission and annually. 

• Maintain ongoing contact with DM 3700 consumers and provide community support services and coordinate other needed services.

• Coordinate with intake to ensure all necessary paperwork and documentation is completed to admit consumers. 

• Provide crisis intervention to consumer’s experiencing a psychiatric or substance use related crisis and utilize clinical judgment in recommending appropriate treatment recommendations, including the need for hospitalization or residential treatment.

• Maintain ongoing contact with hospitalized clients including participation in staffing and discharge planning so that consumers can successfully reintegrate into their living environment. 

• Complete progress notes in AVATAR within 72 hours of service provided which clearly reflect interventions provided and necessity of those interventions.

• Problem solve issues related to housing and housing crisis, accessing community resources to assist with basic needs as well as emergency situations, advocate for consumers in regards to receiving proper health care, and assist consumers in resolving matters of significance.

• Provide stage- based interventions to consumers experiencing co-occurring conditions, utilizing motivational interviewing skills. Make referrals as needed to substance use treatment provider and maintain communication in regards to treatment progression.

• Complete initial and annual Crisis Intervention Plans, Rights and Responsibilities, and all other required paperwork in accordance with agency policy and guidelines.

• Maintains knowledge of agency technology programs and/or systems needed to do the job and uses them effectively.

• Maintains required training and certifications.

• Maintains required agency productivity standards.

• Attends and participates in weekly team meetings and monthly all staff meetings.

• Other duties and/or responsibilities may be assigned by supervisor.

MINIMUM QUALIFICATIONS (KNOWLEDGE, SKILLS, AND ABILITIES)
Education/Certifications: 
• Associates Degree or Bachelor’s degree in the Social Services field or 4 years prior related work- experience required. 
• Active driver’s license and minimum state-required auto-insurance. 
• CPR/First Aid Certification required 

Experience Required: 
• 4 years minimum work-related experience required if no degree. 
• If degreed, 1 to 3 years prior work-related experience preferred. 

Required Knowledge: 
1. Knowledge of behavioral health diagnosis and symptoms. 
2. General knowledge of community resources and/or the willingness to research as needed 

Skills/Abilities: 
• Strong crisis management skills 
• Excellent communication skills, both written and verbal. 
• The ability to use and troubleshoot basic business equipment. 
• The ability to interact with a wide range of individuals. 
• Strong ability to multi-task with a high level of accuracy and timeliness in project output. 
• The ability to maintain a high level of client confidentiality. 
• Ability to problem solve quickly and prioritize tasks for optimum efficiency. 


PHYSICAL DEMANDS AND WORK ENVIRONMENT 
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee is regularly required to drive to local destinations within the catchment area. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is occasionally required to stand; walk; sit; and reach with hands and arms. The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus. The noise level in the work environment is usually low to moderate.