Clinical Behavioral Health Assessor

Job Description

Job Description

Job Description and Requirements

POSITION: Clinical Behavioral Health Assessor 

REPORTS TO: Clinical Director

SUPERVISES: N/A

Purpose:

The Clinical Behavioral Health Assessor is responsible for the quality and accuracy of medical record information in the Clinical Assessment. Extremely Clinically sound in the DSMV for all diagnosis. Ability to ensure submitted documents meet audit compliance from various payors.

Minimum Job Requirements:

1) Licensed or License-Eligible as a LPC, LMSW, LMFT or provisionally licensed for an approved licensure

2) Experience completing Assessments and Individual resiliency Plans preferred.

3) Demonstrated knowledge of mental health disorders and treatment methods.

4) Knowledge of clinical operations and procedures, Medicaid services and documentation requirements.

5) Experience in quality improvement processes, auditing, and clinical documentation.

6) Exceptional verbal and written communication skills.

Position Requires:

• Provision of intensive, integrated, professional mental health services involving treatment planning in a clinical outpatient environment.

• Provision of professional leadership in the determination of appropriate therapeutic approaches and methods.

• Complete supervision of the clinical activities with Clinical Director

• Establishment and maintenance of case files and related documents for clinical and legal purposes

• Active attendance in audits, trainings, office hours and meetings relevant and necessary to this position.

Working Conditions and Physical Effort:

Work is normally performed in an interior/office work environment. No or very limited physical effort

required. No or very limited exposure to physical risk.

Duties and Responsibilities:

• Review assessment to ensure that documentation is complete, accurate, individualized, and that the documentation supports time billed for each assessment, treatment plan, re-assessment and re-assessment treatment plan.

• Ensure the approved COVID-19 (if applicable) statement is in BIRP notes for all assessments and treatment plans.

• Ensure BIRP notes are complete for each assessment and treatment plan billed.

• Review of all types of assessments, (BHA, Initial Assessments, S/A Assesments and IRP’s)

• Ensure appropriate service codes, time in/timeouts, locations, signatures, etc. are on each assessment and treatment plan.

• Ensure diagnosis is supported by the clinical information in the report.

• Ensure compliance of submission and completion of both the assessment and treatment plan.

• Ensure all documentation is signed off per protocol and is audit-ready. All documents match the BIRP notes for service codes, time-in/timeouts, units, and locations are signed for the same DOS with appropriate credentials.

• Ensure appropriate services are recommended based on each individualized assessment.

• Ensure critical assessments are followed through with connection to appropriate services in a timely manner.

• Ensure that Non-Admit Log is complete for all SA clients that refuse Datep program services.

• Ensure that Datep clients are referred for nursing assessment, labs, and SA assessments within 10 days of the initial assessment DOS.

• Communicate any error trends to supervisors in a timely manner and update the Clinical Director and Intake Coordinator with recommendations for suspension or termination if not meeting standards.

• Attend monthly staff meeting

• Ability to communicate in a professional manner verbally and in writing.

• Ability to effectively manage multiple tasks and priorities in a fast-paced environment

• Ability to operate independently and collaboratively as part of a team.

• Ability to anticipate, manage, and adapt to change.

• Skill and ability to make decisions and solve problems.

• Skill and ability to lead and take initiative.