$58,000/year Salary! Bachelor's Degree in Social Services preferred. Up to 34 Paid days off 1st year! Full Benefit Package! CCBHC is an integrated community behavioral health model of care intended to provide integrated, evidence-based, trauma-informed, recovery-oriented and person-and-family-centered care. The CCBHC offers the full array of CCBHC-required mental health, substance use disorder (SUD) and primary care screening services. The Care Coordinator will work in partnership with others as part of a structured inter-disciplinary team, within in a Certified Community Behavioral Health Center (CCBHC) model to coordinate care across the spectrum of health services, including access to high-quality physical (both acute and chronic) and behavioral health care as well as social services, housing, educational systems, and employment opportunities as necessary to facilitate wellness and recovery of the whole person. Care is provided in a culturally sensitive way and is delivered to an adult population who carry a serious mental illness, substance abuse, co-occurring and/or medically co-morbid diagnosis. Bridge Teams provide intensive, community-based services to individuals with severe mental illness. Clients served by Bridge Teams are transitioning from a recent psychiatric hospital discharge to outpatient services. Clients often have complex mental health needs, including acute psychosis, histories of trauma, and co-occurring substance use disorders. The primary function of Bridge Teams is to help reduce unnecessary hospitalizations and incarcerations, by providing individuals the resources essential to thrive and maintain independence in their natural environment. CORE DUTIES & RESPONSIBILITIES • Attend and participate in daily organizational meetings and treatment team meetings with multi-disciplinary team to utilize a team based care approach when working with clients. • Document client progress to maintain a permanent record of client activity according to established methods and procedures. • Demonstrate understanding of various best-practice treatment models to work with individuals with Severe Mental Illness, Co-occurring disorders, and trauma. • Understand the wrap-around focus of CCBHC services, assisting clients in multiple life areas through multi-disciplinary teamwork and community referral. • Obtain and maintain professional licenses and certifications required for the position through attending required trainings, tracking CEU’s, and submitting renewals in a timely manner. • Be familiar with CCBHC standards, understand the history, philosophy, structure and purpose of CCBHC and demonstrate fidelity to the model. • Effectively complete and submit all clinical documentation with established agency timelines. • Coordinate care across the spectrum of health service, including access to high-quality physical (both acute and chronic) and behavioral health care. • Include the Consumer and family members in comprehensive treatment planning. With the adult consumer’s consent, encourage participation of family members and other designated persons in treatment planning and care. • Schedule, coordinate, facilitate daily/weekly treatment team. • Participate in daily/weekly treatment teams. (daily huddles) • Streamline plans of care across the Care Team. • Coordinate care with external health care providers such as pharmacies, PCPs, FQHCs, and DCOs, as well as with behavioral health referrals. Assist consumers and their families with obtaining and keeping referral appointments to outside providers. • Participate in initial treatment plans, strengths and culture preferences, and intakes as needed. Update and modify wrap plans as needed. • Provide individual, family, and/or group services that include screening, coordinating, planning, advocacy, linkage, referral, education, crisis intervention, resource acquisition, and monitoring in a culturally sensitive way. • Track consumers’ admissions and discharges from psychiatric & medical hospitalizations. • Participate in hospital and emergency department discharge processes to transition consumers to a safe community setting according to CCBHC protocols. Ensure timely transfer of medical records, prescriptions, and active follow-up. • Provide high intensity case management and care coordination services to clients following a post psychiatric hospitalization discharge. • Complete data surveys on clients. • Monitor individual health status and service use to determine adherence to or variance from treatment guidelines. • Develop and maintain housing resources for clients experiencing homelessness, including application processes and requirements, document submission, disability application process and submission. May also include outreach to clients in the community. QUALIFICATIONS: Requires Bachelor’s degree in social work or equivalent education. ODMHSAS CMII certification preferred. SKILLS AND KNOWLEDGE: Must obtain Case Management II Certification and Behavioral Health Wellness Coach certification upon hire. TRAVEL AND SPECIAL REQUIREMENTS: Must possess Driver License and use personal automobile for local travel. Must transport clients in personal automobile. CCBHC Model of Care Family & Children’s Services works to heal hurting and abused children, strengthen families, and provide hope and a path to recovery for those battling mental illness and addiction. You will be working in an innovative and dynamic environment using a new transformative model of care Certified Community Behavioral Health Clinic (CCBHC). This model is characterized by innovative, team-based approach and whole person care for adults and children with a range of complex mental health and substance use challenges. Utilizing multi-disciplinary teams, staff work collaboratively to provide a coordinated effort to enhance client recovery. Robust CCBHC services often result in better client outcomes and quality of care due to: • Increased access to care and crisis services • Expanded traditional community mental health and substance use services. • Added Care Coordination and physical health screening for mental health clients • Greater access to Social Services for clients’ economic and social needs • Increased specialized services for veterans, those most in need, and those impacted by the opioid crisis. Drug Free Workplace Policy This job is classified as a “safety-sensitive” position as defined by the Oklahoma Medical Marijuana and Patient Protection Act. Possession of a medical marijuana license will not exclude any applicant; however all employees are subject to the Family & Children’s Services Drug Free Workplace Policy.