Clinical documentation specialist jobs in United States

Under the supervision of the Behavioral Health Supervisor, the Medicaid Assisted Treatment Program Counselor engages the patient in the initial and ongoing treatment processes of the clinic. Conducts a preliminary assessment of eligibility, prepare intake forms, see that the patient is afforded needed services from other disciplines within the agency, and make referrals to outside resources when necessary. Hours: 7AM - 2PM, Mon-Fri Clinic Locations: Brooklyn and Manhattan Salary Range: $50,000 - $60,000 Responsibilities: - On an ongoing basis, the Counselor holds regularly scheduled sessions with all his/her patients concerning their problems and psycho-social needs. - Serves as a Case Manager for each patient to ensure that services are coordinated to meet each assessed need. - Conducts therapy groups. - Assists patients in the identification of problems. - Works with patients in the definition of problems. - Ensures all necessary forms are completed. - Maintains accurate and confidential patient records. - Attends training seminars where instruction on treatment techniques and theories underlying these approaches are provided, and obtain the CASAC credential. - Identifies and records significant data in the case folder regularly. Develops treatment plans for presentation to the IDT. - Holds individual conferences with other disciplines when necessary to facilitate effective treatment throughout the agency. - Meets weekly for clinical supervision with the Behavioral Health Supervisor, concerning work performed, problems encountered in the treatment process, and for case conferences. - Refers to other clinic disciplines when appropriate. - Meets periodically with other staff to obtain feedback necessary for case management and treatment planning. - Performs all forensic collection for patients on their caseload and monitors for treatment related issues in order to update the treatment plan. - Provides vocational/educational assessment, counseling and follow-up for patients not assigned to the Vocational Specialist, as well as voc/ed support and follow-up of all patients as required. - Completes the Vocational Profile Form (HS 305) for each caseload patient. - Provides as an integral service, counseling toward vocational/educational readiness, motivation for vocational rehabilitation, provides initial evaluation for in-house voc/ed services, and provides exploration of voc/ed goals. - Provides patient referrals to the Vocational Specialist and Educational Specialist for in-depth evaluation, counseling and referral for voc/ed programs. - Provides case management, referral follow-up and supportive counseling to patients referred to in-house voc/ed programs and external job/school training. - Meets periodically with the Vocational Specialist and Education Specialist for case consultation and feedback. - Presents vocational treatment objectives at each IDT. - Counselors are expected to work on a rotation basis on Saturdays and select holidays. Assigned shifts may change at the discretion of the Clinical Director according to the needs of the Program. - Performs other duties as assigned by the manager. Qualifications: - CASAC (Credentialed Alcoholism and Substance Abuse Counselor) Certificate required - High School Diploma or GED required. - Possess a demonstrated ability in delivering patient treatment including: communication skills, successful engagement in specialized Human Services training, understanding of human interaction and personality development, and the ability to write and record case documentation. - Understanding of group dynamics is essential. - Must be computer-literate with knowledge of Microsoft Office applications. - Competent in computerized programs that support treatment plans and case notes. - Excellent verbal and written communication skills. - Ability to participate in various committees and work well with others in team settings. - Bilingual in Spanish a plus. **If interested, please apply here:**

Summary: The housing Specialist is responsible for assisting and supporting clients in housing resources, benefits, and placement through the entire treatment experience from admission to discharge; Connects and engages the client to housing resources and support services to aid continuity of care and self-sufficiency post-discharge, monitors the course of treatment for each client in a pro-active manner to minimize the barriers that might compromise the client's treatment and post-treatment living environment. This position requires a strong knowledge of appropriate personal and clinical boundaries, a consistently positive attitude, and the ability to deal with difficult, uncertain, and stressful situations in a positive manner. Provides direct housing casework services to clients living with substance abuse histories in our inpatient substance abuse rehabilitation program. Responsibilities: Conducts client housing needs and risk assessment to determine client housing histories and requirements needed during treatment and post-treatment. Collects client data and connects the client to housing entitlements; follow-up with processing and approval for housing readiness Conducts housing services orientation and referrals. Meet with clients on caseload according to regulations and policy to identify client housing needs and progress towards meeting housing goals. Assist client with creating an individualized housing case management plan that will outline the client's goals and housing objectives, as part of the multidisciplinary team. Conducts individual and group services in accordance with a treatment plan including housing options, housing entitlements, benefits, and community resources. Assist with client crisis; communicates with managerial, clinical, and support staff when clients' needs demand additional monitoring or attention when experiencing a crisis, etc. Ability to redirect and de-escalate crisis situations, conduct emergency management, and has an understanding of proper emergency procedures. Document all client care in EHR and records/reports all client/staff incidents as required. Meets with the client according to the care plan to review and discuss discharge plans, continuing care, and community resources needs (continued treatment, entitlements, housing, etc.) Create community housing and entitlement resource banks, make client referrals, and follow up on all referrals. Escort client to appointments as needed. Conduct post-discharge follow-up and document all in the client record and reporting forms. Maintain the charts of clients in accordance with OASAS and agency requirements; Participate in weekly Clinical Team Meetings. Qualifications: Bachelors Degree in social services, counseling, or related area required. Housing case management experience needed. Minimum of two years housing case management experience working with the substance abusing and/or homeless populations preferred. Bilingual Spanish/English preferred. Must have exceptional communication skills both orally and in writing, with individuals and groups regarding confidential and sensitive issues.