USA

Transition Navigator

Phoenix - Arizona (AZ),

Community Bridges Inc.

Job Description:

Specific Functions & Duties: Each discipline is governed by specific policy and process. It is the responsibility of the employee to read and learn the associated policy and processes as they will be held responsible for carrying out their duties in a competent and ethical manner.

Patient Enrollment

  • Completes or updates assessment and treatment plan documentation and enrolls patient with outpatient clinic.
  • Communicates on the status of each assigned patient with the Clinical Lead.
  • Is assigned as the Primary Staff Assigned for these patients until patient has transitioned to the outpatient level of care.

Coordination of Care

  • Ensures that each patient under their care receives coordination with all parties currently identified as having an active role in their ongoing treatment and/or life and releases of information are completed.
  • Communicates on the status of each assigned patient with the Clinical Lead.
  • Serves as a patient advocate ensuring that services that the client is connected with are being received.
  • Navigates identified services or benefits patients are in need of and assists the individual in accessing these services.
  • Implement skills learned during on-the-job training and required competencies related to the program and ensuring that all required documentation is completed prior to the end of shift.
  • Protects each patient’s confidentiality within the guidelines of established policy and process.
  • Adheres to established policy and process for this assignment.
  • Other duties as assigned by supervisory and administrative support.

Outreach, Follow-Up, & Re-Engagement.

  • Actively outreaches and engages patient from time of crisis discharge to first appointment with outpatient clinic or team.
  • Will provide transportation services to patients to initial clinic appointment as needed
  • The Navigator will follow up and assist with implementation of the needs identified as directed by the Peer Services & Outreach Assistant Manager.
  • Implement skills learned during on-the-job training and required competencies related to the Program and ensuring that all required documentation is completed prior to the end of shift.
  • Other duties as assigned by supervisory and administrative support.

Continuing Care

  • Assists the patient in the identification of needs for ongoing recovery, housing, and stabilization in the community.
  • Develops and collaborates with an extensive network of community based and professional resources. A Transition Navigator must know how to access various social/behavioral health community-based services that can include but is not limited to food, clothing and supportive services.
  • Implement skills learned during on-the-job training and required competencies related to the program and ensuring that all required documentation is completed prior to the end of shift.
  • Adheres to established policy and process for this assignment.
  • Other duties as assigned by supervisory and administrative support.

Individual Support

  • Provide emotional support to individuals who appear unsure or fearful, through the use of calm reassurances, positive feedback, and sharing of personal recovery as appropriate.
  • Incorporate Motivational Interviewing techniques into interactions with individuals in program to empower them to achieve their goals of being housed and being permanently stable in the community.
  • Will act as a short-term recovery mentor, helping the patient develop and implement self directed recovery plan, sharing experience, providing support, teaching self management techniques, and reassurance.
  • Assist the individual in understanding the necessity for continued care and support through the program involvement. Giving referrals when appropriate.
  • Implement skills learned during on-the-job training and required competencies related to the program and ensuring that all required documentation is completed prior to the end of shift. .
  • Other duties as assigned by supervisory and administrative support

Customer Service

  • Provide patients and any parties involved in their continuum of care with dignity and respect.
  • Provide community stakeholders (police, fire, probation, businesses, clergy, insurance companies, providers, health plan staff, concerned citizens, etc.) are treated with the utmost respect and assisted to the best of our ability in each case. Never saying “no” but always assisting each request within the context of the agency mission and purpose. Is evidenced by not receiving a community complaint or excelling in the area of customer service.
  • Implement skills learned during on-the-job training and required competencies related to program and ensuring that all required documentation is completed prior to the end of shift.
  • Other duties as assigned by supervisory and administrative support

Documentation

  • Document all services provides and the specific interactions with patients in the patient’s electronic medical record.
  • Complete documentation prior to the end of shift.
  • Correct all deficiencies identified within five days of being notified.
  • Complete and deliver all Incident Reports or Significant Events, prior to the conclusion of the shift where the incident occurred, as specified in Community Bridges Policies and Procedures.
  • Implement skills learned during on-the-job training and required competencies related to the program and ensuring that all required documentation is completed prior to the end of shift.
  • Other duties as assigned by supervisory and administrative support


Skills Necessary to Perform Assigned Tasks
and ongoing performance that each individual will be measured against in addition to those noted above:

    • Reading & Comprehension: Must have the ability to read and comprehend information without
difficulty.
  • Documentation: As evidenced by all work being completed by the end of scheduled shift and in adherence with A.A.C. R9 – 20 – 208, 209, 210, & 211, the ADHS/DBHS Provider Manual, and Community Bridges established documentation standards in process and policy.
  • Typing Skills: This position requires the specialist to type 30/wpm.
  • Computer Skills: Familiar with Microsoft systems such as Outlook, Word, and Excel.
  • Linguistic Ability: Demonstrates the ability to coherently communicate with others.
  • Foreign Language: Not required for this position but is helpful and is strongly encourage.
      • Analytical: Demonstrates an ability to synthesize complex information and report it to others in a calm and precise manner.
      • Reasoning Ability: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
      • Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of costumers or employees of organizations.
      • Interpersonal Relations: Works well with others and can be depended upon to follow through with task completion, and be available to assist.
      • Chain of Command: Follows the established chain of command and does not create situations that would call into question the authority of supervisor or impede their ability to manage the facility or program.
    • Ethics: Adheres to a principle of “Do No Harm” by demonstrating personal integrity in interactions with staff, patients, and public. This is also demonstrated by one’s ability to perform assigned duties in a competent manner without the violation of Community Bridges policies/processes, patient and/or employee rights, or violation of State, Federal, or local laws.
    • Agility: Able to move around quickly and freely in response to crisis situations.
      • Physical Abilities: Must be able to move and/or lift a minimum of 150lbs.
      • Quality: Performs work neatly and completely. All work is completed within the time allowed for task per policy.
    • Customer Service: Ensures that community stakeholders (police, fire, probation, businesses, clergy, insurance companies, providers, health plan staff, concerned citizens, etc.) are treated with the utmost respect and assisted to the best of our ability in each case. Never saying “no” but always assisting each request within the context of the agency mission and purpose. Is evidenced by not receiving a community complaint or excelling in the area of customer service.
      • Patient Care: The extent to which the employee promotes empathy, warmth, understanding, and treats each patient with respect and dignity always keeping in mind their cultural, psychological, medical, social, and humanistic needs.
      • Assessment & Triage: Assessments are accurate as to the patient’s presenting issue while respecting the individual’s cultural, psychological, social, and medical status. Assessments are conducted within the timeframe and context identified in policy and process and is appropriate in their use for developing a plan of action for the seamless transition to the next appropriate level of care.
    • Patient Care Planning: The extent that the designated (treatment, continuing care, health & wellness, discharge) plan developed by the employee is in conjunction with the goals of the patient as well as those areas identified in his or her associated assessment that require attention.
    • Problem Solving: Identifies and resolves problems in a timely manner; Develops alternative solutions.
    • Judgment: Displays willingness to make decisions; Exhibits sound and accurate judgment.
    • Motivation: Sets and achieves challenging goals.
    • Oral Communication: Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions.
    • Written Communication: Writes clearly and informatively.
    • Quality Management: Looks for ways to improve and promote quality.
    • Organizational Support: Follows policies and procedures; Supports organization’s goals and values.
    • Organization: Prioritizes and plans work activities; Uses time efficiently; sets goals and objectives.
    • Professionalism: Approaches others in a tactful manner; treats others with respect and consideration regardless of their status or position.
    • Safety and Security: Observes safety and security procedure; Reports potentially unsafe conditions.
      • Quantity: Meets productivity standards.
      • Adaptability: Adapts to changes in the work environment; changes approach or method to best fit the situation.
      • Innovation: Displays original thinking and creativity; meets challenges with resourcefulness; Generates suggestions for improving work.
    • Scope of Practice: The extent to which the individual remains focused on their professional skill and does not deviate into areas for which they have no training or expertise.
    • Attendance: Remains alert and awake throughout the entirety of a scheduled shift. Schedules time off or other related absences within the time allotted by Community Bridges Policy and adheres to the policies around absenteeism.


    Experience

    Required
    • 2 year(s): Minimum of 2 years of mixed behavioral and physical health work experience and/or 2 years of substance abuse/mental health recovery oriented service.

    Education

    Required
    • High School or better

    Licenses & Certifications

    Preferred
    • 39 MVR Report

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