1. Participate in the Wraparound model of collaboration within the Child Family Team model as it pertains to the development of self-management health goals to be included in the service plan.

2. Facilitate regular contact via phone calls and face to face meetings with youth/family to monitor progress and provide support for the self-management goals includes in the service plan.

3. Engage assigned child and families in health promotion planning and activities, including the provision of motivational interventions to increase treatment and medication compliance and support lifestyle changes.

4. Provide health education specific to chronic conditions of assigned youth.

5. Facilitate the engagement of youth and families in community supports which may include preparing youth and family for pending appointments and accompanying youth and families on appointments to reduce youth/family apprehension.

6. Participate in transitional care and follow-up planning on assigned youth.

7. Adhere to Medicaid standards and regulations governing targeted case management.

8. Meet with the Nurse Manager on a regular basis for consultation and supervision

9. Ensure that documentation is posted within the electronic record and filed in hard chart within required time frames and compliant with the applicable regulatory standards.

10. Comply with Agency required critical/unusual incident report protocol.

11. Identify new community resources and barriers, and ensure this information is conveyed to the Community Resource Director.

12. Collaborate with the Nurse Manager to identify, monitor and report outcome measures of BHH care management.

13. Adhere to the Agency Code of Ethics in addition to applicable professional boards and maintain appropriate professional demeanor and personal appearance.

14. Adhere to HIPAA standards and maintain client confidentiality.

15. Ensure individual punctuality at all required meetings.

16. Attend all required Agency and outside trainings.

17. Attend meetings and events as designated by Management.

18. Comply with all of the Agency’s policies and procedures as specified in the Employee Handbook.

19. Perform all additional responsibilities as assigned by members of Executive Management Team.

CORE COMPETENCIES:

• INTERPERSONAL COMMUNICATION: The ability to establish rapport quickly and to communicate effectively with youth, their family members and other providers.
• COLLABORATION & TEAMWORK: The ability to function effectively as a member of an inter-professional team that includes behavioral health and primary care providers, youth and family members.
• SCREENING & ASSESSMENT: The ability to conduct brief, evidence-based and developmentally appropriate screening and to conduct or arrange for more detailed assessments when indicated.
• CARE PLANNING & CARE COORDINATION: The ability to create and implement integrated care plans, ensuring access to an array of linked services, and the exchange of information among youth, family members and providers.
• INTERVENTION: The ability to provide a range of brief, focused prevention services, facilitating health treatment services.
• CULTURAL COMPETENCE & ADAPTATION: The ability to provide services that are relevant to the culture of the youth and their family.
• SYSTEMS ORIENTED PRACTICE: The ability to function effectively within the organizational and financial structures of the local system of healthcare.
• PRACTICE-BASED LEARNING & QUALITY IMPROVMENT: The ability to assess and continually improve the services delivered as an individual provider and as an inter-professional team.
• INFORMATICS: The ability to use information technology to support and improve integrated healthcare.

EDUCATION | EXPERIENCE | SPECIAL SKILLS

• Minimum Bachelor’s Degree in nutrition, public health, health education OR related field
• CHES® certified, or eligible to sit for examination
• Bi-lingual language skills preferred
• Maintain a high level of teamwork, leadership, and professionalism
• Culturally competent and responsive
• Excellent public speaking and interpersonal communication skills
• Ability to work with energy, creativity, and enthusiasm on assigned teams
• Experience with community relations, resource development, and Wraparound process are a plus
• Ability to work under supervision and as a part of community team
• Valid driver’s license is required; MUST maintain required vehicle insurance