Primary Job Functions:
Clinical Responsibilities:
- Provides effective clinical assessment of the consumer at intake and continuously thereafter.
- Completes a DLA-20 at intake, and every 90 days thereafter for group home consumers.
- Utilizes assessment data to support a DSM V diagnosis; updates diagnoses as needed.
- Utilizes screening tools (BPRS, GAD 7, PHQ 9) as appropriate.
- Formulates a person centered, recover oriented, medically appropriate treatment plan along with consumer that proves medical necessity and obtains signatures each time the plan created, updated and/or revised.
- Provides individual, group, and family therapy, utilizing evidenced based and research-based models and theories according to consumer needs as stated in the treatment plan
- Provides referrals when needed to internal and external agencies and documents the referral and follow up in the Medical Record
- Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation.
- Effectively collaborates with the treatment team members and outside sources in the delivery of clinical services.
- Evaluates the consumer for discharge planning – provides appropriate referrals and/or linkage and closes chart appropriately and in a timely manner.
- Effectively demonstrates the application of adult specific competencies.
Supervision and Consultation:
- Seeks clinical supervision and consultation as needed.
- Accepts and employs suggestions for improvement.
- Actively works to enhance clinical skills.
Clinical Record Keeping:
- Documents in a timely fashion per AltaPointe policy
- Documents appropriate, complete, and clinically comprehensive mental health assessments – including diagnostic impression and referrals.
- Documents measurable and specific problem statements, goals, and objectives in the treatment plan
- Documents in a clear and concise manner treatment goals and objectives addressed, interventions provided, techniques used, consumer progress and response in direct service record.
- Documents case disposition, case closings, follow-up and referrals.
- Documents legibly and includes credentials with all signatures.
Case Load Management:
- Effectively manages caseload based on consumer needs.
- Meets AltaPointe productivity standards.
Courteous and respectful attitudes towards consumers, visitors, and co-workers
- Treats consumers with care, dignity and compassion
- Respects consumers privacy and confidentiality.
- Is pleasant and cooperative with others.
- Assists visitors and consumers as needed.
- Personal values do not inhibit ability to relate and care for others.
- Is sensitive to the consumers needs, expectations and individual differences.
Administrative and Other Related Duties as Assigned:
- Actively participates in Performance Improvement activities.
- Actively participates in AltaPointe committees as required.
- Completes assigned tasks in a timely manner.
- Accesses appropriate community resources according to consumer needs
- Follows AltaPointe policies and procedures.
- Attends required in-services and workshops.
- Attends scheduled outpatient educational groups for therapists regularly.