Homeoffice Holon Health - Arizona Care Navigator (Licensed Counselor) at Holon Health

The Clinical Care Navigator functions as the primary care coordinator for patients and collaborates with key clinical staff and providers to ensure comprehensive care and treatment from providers. By utilizing comprehensive assessments and root cause analysis, including the use of standardized tools of measurement, you will participate in the development of an individualized care management plan to support health improvements. In cooperation with Holon Health’s medical team, you will evaluate the diagnoses and interventions recommended to support each patient’s total care. When communication with existing providers or referrals to new providers are determined beneficial, you will facilitate conversations and collaboration of an interdisciplinary Care Team supporting medical, behavioral health, SUD and specialty care while also assisting to remove barriers associated with social determinants of health.

While patients may be waiting for services through outside referrals for BH or SUD to begin, you will provide brief, solution focused interventions and motivational therapy to maintain active engagement and perhaps begin to alleviate some of the stressors which have caused struggles or prevented a patient from being able to obtain appropriate care. You will support the community-based service providers by helping to prepare the patient to receive more intensive, specialized treatment; and you will continue to monitor progress through re-assessments and regular dialogue with the patient as services continue. In many cases, you will act as a liaison between the service providers and the courts. In addition to our collaborative care management solution, you will assist with the rollout and management of our proprietary digital therapeutic application which serves as an adjunct to treatment.

Specifically, you will:

• Utilize active listening and written communication skills to interact with members by phone, video, messaging, email, and in-person.
• Provide consultation, psycho-education, and motivational assistance to address mental health, substance use, and family/relationship concerns.
• Assess for risk and manage member crises by providing in-the-moment support, triage, safety planning, and follow up.
• Conduct a clinical needs assessment to develop a plan of action for each member and refer to an appropriate level and modality of care (internal therapy or physician providers, external benefits, or community resources).
• Synthesize information that must be gathered from various sources and apply good clinical judgement in order to make determinations about interventions, follow up, and ongoing support needs.
• Implement measurement-based case management practices to improve member functioning and outcomes by monitoring treatment progress and promoting collaborative, effective care through our providers.
• Identify and problem-solve issues that serve as a barrier or disruption to care, with support from leadership.
• Provide brief, solution focused interventions and offer motivational interviewing techniques to support on-going engagement in collaborative care support services
• Act as a liaison and advocate between the individual and other supportive influences, primary care, and other facilities/agencies. Provide clinical consultation to physicians, professional staff, and other teams members to provide optimal quality patient care and effective solutions.
• Interacts continuously with the Consulting Medical Director and on-site provider to determine appropriate behavioral action(s) needed to address medical and psychosocial needs. Review benefits options, research community resources, create solutions, and enable each individual to be active participant in his/her own care.
• Ensure individuals are engaging with the wellness care providers and PCP to complete their care management plan or preventative care services
• Participate in staff meetings, case consultations, and trainings
• Establish and retain member referral systems from care coordination systems
• Maintain thorough documentation of all member encounters and complete reporting requirements according to organization standards.

• An active, independent license (ex. LCSW, LPC, LMFT, LISAC, etc.) in the state(s) of practice
• A Master's degree in Psychology, Social Work, Counseling, or related field
• 2+ years of experience in SUD or BH management and/or acute BH care setting; 1+ year of experience in a clinical environment
• Working with the needs of vulnerable populations who have chronic or complex bio-psychosocial needs
• Proficiency in technology including frequent use of Electronic Health Records, computer systems, telehealth platforms, and general Microsoft Office tools
• Knowledge of Motivational Interviewing, Cognitive Behavioral Therapy, Brief, Solution Focused Interventions, Mindfulness practices preferred
• Excellent listening, written, and verbal communication skills
• Ability to work independently and a s part of a team
• Motivated to go above and beyond to support patients, promoting a high-touch, supportive resource relationship.
• Familiarity with community resources and supports as well as an ability to research and outreach to find available solutions
• Stable, high-speed internet