Medical Record Lead - Shallotte, NC, United States - Southeastern Integrated Care LLC

Description

Summary:
The Team Leader is responsible for the supervision and management of team operations and staffing.

Team Leader ensures that services are provided to the members served to meet the clinical needs of each recipient through direct and indirect interventions.

Essential Duties and Responsibilities:

• The team leader (clinical supervisor) must provide individual therapy for recipients served by the team.
• Behavioral interventions such as modeling, behavior modification, and behavior rehearsal.
• Designates the appropriate team staff so that specialized clinical expertise is applied as clinically indicated for each recipient.
• Provides, coordinates, and oversees initial assessment and ongoing assessment of the recipient's clinical needs.
• Develops and implement individualized supervision plans for team members.
• Provides clinical supervision of all members of the team for the provision of this service.
• Determines team caseload by the level of acuity and the needs of the individual served.
• Facilitates weekly team meetings.
• Monitors and evaluates the services, interventions, and activities provided by the team.
• Provide clinical expertise and guidance to the members in the team's interventions with the recipient.
• Development of relapse prevention and disease management strategies to support recovery.
• Psycho-education for the recipient, families, caregivers, and/or other individuals involved with the recipient about the recipient's diagnosis, symptoms, and treatment.
• Performs Intensive Case Management functions of linking and arranging for services and referrals.
• Participates in the initial PCP and revision of the Person-Centered Plan (PCP) as needed.
• Ensure and monitor the implementation of the PCP.
• Spends time at the location where services are being performed as specified in the service definition for that service.
• Participates in a first responder on-call system available to consumers and/or his/her natural support network on a 24/7/365 basis; coordinates "first response" resources according to consumer needs and the PCP.
• Works closely with other clinical/professional staff to maintain communication and provide feedback, standardize procedures and expedite PCP implementation.
• Conducts and supervises formal investigations into incidents/allegations of abuse, neglect, exploitation, or other circumstances that may present a risk to the safety and health of the person supported.
• Ensures that all initial and reauthorizations for services occur in a timely fashion.
• Provides timely and accurate information when requesting authorizations from the LME/MCO/Statewide Vendor and follows up on each request for authorization modified, not approved, and/or not responded to.
• Notifies appropriate parties upon the denial/modification of continued services and provides person-supported/guardian DMA-approved appeal policies and materials.
• Monitors utilization of service to ensure that it is effective, appropriate, and within the limits set forth in both rules, PCP, and the service authorization.
• Coordinates transition to another level/type of care for the person supported.
• Coordinates and oversees the discharge planning process including the development of a discharge plan initially upon admission and a discharge summary with follow-up resources at the conclusion of services.
• Facilitates relationships and serves as a link between the company, consumer, guardians, local agencies, and the community.
• Drafts responses to and implements changes required by Medicaid, the Department of Facility Services, and/or other regulatory agencies.
• Performs all other duties as reasonably required and assigned.
• Practices standard medical precautions by understanding and utilizing personal protective and safety equipment.
• Ensures confidentiality regarding sensitive and protected information.
• Ensures individual rights to privacy and protected health information for the person supported.
• Maintaining records and charting each individual and reporting unusual and critical incidents in a professional, timely manner (within 24 hours).
• Familiarization with medications used by the client and policies. regarding medication administration.
• Represent the company in a positive manner, reflective of the company's mission, at all times.
• Ensures confidentiality regarding sensitive and protected information.
• Ensures individual rights to privacy and protected health information for the person supported.
• Ensures service, agency, LME/MCO, state and/or federal documentation requirements and timelines such as NCTOPPs, PCPs/ITRs, and reminders relative to Clinical Monthly Summaries, Discharge Summaries, and Aggregate Reports.
• Completes Intake Packets for any of the referrals that the office receives.
• Accurately documents all billable encounters into Southeastern Integrated Care's EMR (electronic medical record) system within 24 hours. Any corrections will be entered within 24 hours of being notified.
• Other duties as assigned.
• In addition, the employee must participate in all required training and education as mandated by the specific service line and clinical coverage policy.

Supervisory Responsibilities:

The team leader supervises all members of the team demonstrating the knowledge, skills, and abilities for this role as required by the population and age served.

Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education/Experience

• Master's degree in human services-related field required.
• Must have a minimum of one (1) year of documented prior experience working with the population served with MH/SA diagnosis. OR
• Three years of clinical experience with SPMA, with a minimum of two years post-graduate. (ACT only)

Required Skills/Abilities

• Must maintain strict confidentiality.
• Must possess effective communication/documentation skills.
• Ability to learn and use personal computers. Work with a computer is common and the ability to understand word processing and certain spreadsheet programs is important.
• Successfully complete other training as may be required or amended by company policy.
• Develop organizational and communication skills that foster TEAMWORK.
• Requires flexibility in scheduling and availability to adequately meet the service needs of the consumer/family and other team members.
• Must have reliable transportation and be willing to travel locally.
• Must meet 10A NCAC 27G.0104

Certificates, Licenses, Registrations

• Licensed Psychologist, LPA, LCSW, LCSW-A, LCMHC, LCMHC-A, LMFT, LMFT-A.
• Valid NC driver's license including personal vehicle insurance coverage.
• Current license must be maintained.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work is performed primarily in the client's living environment and in the community and may involve exposure to cigarette smoke, domestic animals/pets, household pests, uncomfortable heating/cooling, and other issues related to the domestic location in which service is delivered.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand; walk; use hands to finger, handle, or feel objects, tools, or controls; talk and hear; and taste and smell.

The employee frequently is required to reach with hands and arms and stoop, kneel, crouch, or crawl. The employee is occasionally required to sit and climb or balance.

The employee must be able to lift and/or move up to 20 pounds and occasionally lift and/or move up to 50 pounds.

Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Must be able to drive and operate a personal vehicle safely and adhere to all applicable state and traffic laws.

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