System Navigator (Registered Nurse or LPN)

MnTC•Minneapolis, MN

1d•$62,000 - $72,000

About The Position

Work where you matter! Mn Adult & Teen Challenge is a leader in the recovery community, offering a broad spectrum of treatments services and recovery programs for men, women, and teens across Minnesota. As a part of our team, you’ll find a workplace with strong values, invested managers, and supportive co-workers as well as numerous awards, including Newsweek’s “Best Addiction Treatment Center” and six time recipient of the Star Tribune's “Top Work Places.” Job Summary The Systems Navigator takes the lead in conducting assessment and planning for Behavioral Health Home Services, care coordination, meeting with each member as necessary to assess needs, review progress, make and assist with referrals, and provide health and wellness education, direct support and advocacy for individuals served. Essential Job Duties/Responsibilities: To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily. Management may modify, change or add to the duties of this job description at any time without notice. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The essential functions include the following: Conduct an Intake Interview and Brief Needs Assessment for each person referred. Ensure that the person enrolled in BHH services receives information about the purpose of BHH services and the person’s rights and responsibilities Providing coaching to members and their identified supports regarding BHH services Notify the Managed Care Organization (if appropriate) the patient is being enrolled in a BHH using the form provided by the Department of Human Services. Coordinate a meeting for each person referred with the Integration Specialist. Meet with the client, gather information and complete the Health and Wellness Assessment. Using a person-centered interview, and information gathered in assessments, develop measurable goals and objectives for the Health Action Plan. Submit to the Integration Specialist when complete, for review and approval, and obtain the individual's signature. Update the health action plan at least once every six months, or more frequently if there are significant changes to a person’s needs or goals. Conduct regular Progress Reviews on the Health Action Plans for each individual at the intervals required in the Behavioral Health Home Services policy and procedure guide and update the plan every six months for individuals who are continuing services. Attend regular (no less often than monthly) meetings with the Integration Specialist and Qualified Health Home Specialists to consult and collaborate, identifying priority cases for discussion based on member needs. Help individuals prepare for and attend recommended health care, behavioral health, social services, vocational supports, and other appointments. With members, identify potential needs and barriers to accessing necessary services and arrange for necessary supports (arranging transportation, attending with, advocating on behalf of individuals, or teaching self-advocacy skills). Develop competency in providing member Health and Wellness Education using resources approved by the Integration Specialist. Develop and demonstrate competency in using Motivational Interviewing skills to help individuals overcome ambivalence or resistance in pursuing positive health and wellness goals. Refer people to resources appropriate to their screening results. Know processes for referrals related to substance use disorder and ensure follow-through with referrals. Demonstrate capacity to integrate a treatment plan for substance use disorder into comprehensive care planning. Have capacity to assess a person’s readiness for change and his or her capacity to integrate new health care or community supports into his or her life. Develop an articulate health and wellness vocabulary that will engender confidence in providers of health care and social services to the individuals we serve in common. Nurture positive and productive partnerships with providers with proactive communication and by providing information and education about the Behavioral Health Home Service, its purpose, goals and benefits to persons served. When individuals receive other services within the agency, take the lead in facilitating collaboration to optimally support the individual's recovery and health goals. Offer and schedule and facilitate individual Recovery Team Meetings in conjunction with Health Action Plan and other Treatment Plan development or updates. Manage time effectively to ensure quality and compliance with all assessment and planning requirements. Maintain accurate and complete records of all services provided and health care records of persons served. Report incidents, potential maltreatment, and sentinel events immediately (within 24 hours) to the Integration Specialist. Meet weekly with Qualified Health Home Specialist partner(s) to review the previous week and collaborate on upcoming needs of individuals served. Review contact records with all persons served to see that they, or a primary care provider for them have had contact within the last 30 days and that all identified needs have been met. Participate in ongoing Career Development, working toward career and competency improvement goals identified in the plan.

Requirements

Registered Nurse (or LPN) with a minimum of 2000 hours providing services to individuals with mental illness or substance use disorder as defined in section 245I.04, subdivision 4
A mental health practitioner as defined in Minnesota Statutes, section 245.4871, subdivision 26 or Minnesota Statutes, section 245.462, subdivision 17
A community health worker as defined in section 256B.0625, subdivision 49

Responsibilities

Conduct an Intake Interview and Brief Needs Assessment for each person referred.
Ensure that the person enrolled in BHH services receives information about the purpose of BHH services and the person’s rights and responsibilities
Providing coaching to members and their identified supports regarding BHH services
Notify the Managed Care Organization (if appropriate) the patient is being enrolled in a BHH using the form provided by the Department of Human Services.
Coordinate a meeting for each person referred with the Integration Specialist.
Meet with the client, gather information and complete the Health and Wellness Assessment.
Using a person-centered interview, and information gathered in assessments, develop measurable goals and objectives for the Health Action Plan.
Submit to the Integration Specialist when complete, for review and approval, and obtain the individual's signature.
Update the health action plan at least once every six months, or more frequently if there are significant changes to a person’s needs or goals.
Conduct regular Progress Reviews on the Health Action Plans for each individual at the intervals required in the Behavioral Health Home Services policy and procedure guide and update the plan every six months for individuals who are continuing services.
Attend regular (no less often than monthly) meetings with the Integration Specialist and Qualified Health Home Specialists to consult and collaborate, identifying priority cases for discussion based on member needs.
Help individuals prepare for and attend recommended health care, behavioral health, social services, vocational supports, and other appointments.
With members, identify potential needs and barriers to accessing necessary services and arrange for necessary supports (arranging transportation, attending with, advocating on behalf of individuals, or teaching self-advocacy skills).
Develop competency in providing member Health and Wellness Education using resources approved by the Integration Specialist.
Develop and demonstrate competency in using Motivational Interviewing skills to help individuals overcome ambivalence or resistance in pursuing positive health and wellness goals.
Refer people to resources appropriate to their screening results.
Know processes for referrals related to substance use disorder and ensure follow-through with referrals.
Demonstrate capacity to integrate a treatment plan for substance use disorder into comprehensive care planning.
Have capacity to assess a person’s readiness for change and his or her capacity to integrate new health care or community supports into his or her life.
Develop an articulate health and wellness vocabulary that will engender confidence in providers of health care and social services to the individuals we serve in common.
Nurture positive and productive partnerships with providers with proactive communication and by providing information and education about the Behavioral Health Home Service, its purpose, goals and benefits to persons served.
When individuals receive other services within the agency, take the lead in facilitating collaboration to optimally support the individual's recovery and health goals.
Offer and schedule and facilitate individual Recovery Team Meetings in conjunction with Health Action Plan and other Treatment Plan development or updates.
Manage time effectively to ensure quality and compliance with all assessment and planning requirements.
Maintain accurate and complete records of all services provided and health care records of persons served.
Report incidents, potential maltreatment, and sentinel events immediately (within 24 hours) to the Integration Specialist.
Meet weekly with Qualified Health Home Specialist partner(s) to review the previous week and collaborate on upcoming needs of individuals served.
Review contact records with all persons served to see that they, or a primary care provider for them have had contact within the last 30 days and that all identified needs have been met.
Participate in ongoing Career Development, working toward career and competency improvement goals identified in the plan.