Forensic Housing Transition of Care Coordinator (MHP)

Job Details: Job Location: TMBH-ASO/OHRS - Lacey, WA 98503, Position Type: Full Time, Education Level: Graduate Degree, Salary Range: $38.10 - $46.01 Hourly, Job Shift: Day, Olympic Health and Recovery Services is a dynamic organization serving the most vulnerable in our communities. Join us in our mission to provide access to an effective, reliable safety net of behavioral health crisis and recovery support services throughout our region.

The FHARPS Transitions of Care Coordinator serves as a bridge for individuals experiencing behavioral health challenges transitioning from inpatient or correctional facilities to the community with the support of FHARPS peer and housing services. The role emphasizes early engagement, collaborative planning, and reducing barriers to improve outcomes for individuals referred to FHARPS. This position is responsible for managing referrals from DSHS forensic partners and other community providers, conducting outreach and engagement with eligible individuals, re-engage participants who have disengaged with the program, maintain data entry in support of contract deliverables, and build provider and community relations to support continuity of care for individuals transitioning from institutional settings. This position reports to the FHARPS Program Supervisor.

Salary Range: $38.10 - $46.01 per hour DOE.

Schedule: Monday-Friday, 8am-5pm.

TMBH-ASO/OHRS provides comprehensive benefits for full-time employees including medical/dental/vision plan options (many with no employee paid monthly premium depending on plan choice, and dependent coverage options), and life insurance and disability insurance options. Eligible employees participate in WA State PERS retirement plans and employees may elect additional pre and post tax deferred compensation retirement options. Employees receive a PTO package earning a minimum of 140 hours annually and 12 paid holidays. Other tax deferred options include Flexible Spending Accounts (FSA), and Health Savings Accounts (HSA).

OHRS is an approved Public Student Loan Forgiveness employer. We pay the fees for required DOH licenses for the position, and we offer annual professional development funds.

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Brief Overview of Major Responsibilities

• Assists in screening and tracking all referrals to FHARPS.
• Engage early with individuals to anticipate discharge or release needs for a successful transition to FHARPS services.
• Collaborate with hospitals, residential facilities, and community providers to develop comprehensive transition plans.
• Conducts regular in-reach to local jails, hospitals, crisis facilities, court systems, and additional agencies to locate, enroll, and/or engage FHARPS eligible referrals and FHARPS participants.
• Conducts regular outreach in collaboration with Trueblood programs, Balance of State Continuum of Care organizations, and other local partners to locate, enroll, and engage FHARPS-eligible referrals and participants.
• Educates and informs referred individuals about program requirements and expectations with the goal of enrollment into FHARPS.
• Engagement is likely to provide support to individuals with acute behavioral health presentation.
• Develop release plans and emergency/ transitional housing plans with individuals and provide ongoing care coordination.
• Facilitate referrals for case management, aftercare, and recovery support services post-FHARPS.
• Foster positive working relationships with Thurston and Mason County behavioral health providers, community organizations, and county agencies.
• Transport participants as deemed necessary. Transportation should be limited to housing related needs.
• Builds relationships with community resources and delivers coordination, support, and advocacy to program participants facing challenges such as homelessness, chronic mental or behavioral health conditions, legal issues, and/or substance use disorders.
• Establishes and maintains partnerships with local behavioral health, housing, and healthcare agencies to streamline referrals and strengthen the continuum of care for eligible participants.
• Responsible for supporting various program data entry requirements in electronic health records system and excel, compiling and maintaining records and reports as assigned.
• Participate in scheduled Hospital Diversion Team meetings, weekly FHARPS staff meetings, and other internal or external meetings as needed.
• Participates in monthly meetings with system partners, including DSHS Navigators, Health Care Authority, and DSHS program leads.
• Coordinates with other Trueblood projects to include Forensic Projects for Assistance in Transition from Homelessness (FPATH), Outpatient Competency Restoration Program (OCRP), the Forensic Navigators (FN), Crisis Housing Vouchers (CHV), and others to provide effective case management services and care coordination.
• Collaborate with tribal communities, UIHP non-Tribal IHCPs and staff, and other tribal behavioral health programs.
• Demonstrates the OHRS mission, purpose, values, and beliefs in everyday language and contact with internal and external stakeholder.
• Performs related work, special projects or other duties as assigned.

Qualifications: Education, Experience, & Qualifications

• Meets WA state qualifications to be a Mental Health Professional.
• Master’s degree or further advanced degree in counseling or one of the social sciences from an accredited college or university. Or bachelor’s degree in counseling in one of the social sciences and five (5) years of direct behavioral health experience.
• WA Department of Health license or associate license as a Social Worker, Mental Health Counselor, Marriage and Family Therapist, Psychologist or BSN/RN. Or WA DOH Licensed or Certified Agency Affiliated Counselor license (LAAC or CAAC).
• Two (2) years of administrative and/or clinical experience within a social service or a closely related environment preferred.
• Current Washington State Driver's License, proof of insurance, and satisfactory drivers record that meets insurance coverage requirements.
• Satisfactory criminal background clearances and excluded party sanctions.
• Must be able to obtain and maintain clearance at local correctional facilities, including Thurston County Jail, Mason County Jail and Nisqually Jail.

Skills and Abilities

• Ability to anticipate needs and act proactively to prevent service gaps.
• Strong critical thinking skills, ability to conceptualize and implement creative solutions.
• Ability to exercise sound judgment, manage responsibilities independently, and collaborate effectively with team members and community partners.
• Ability to work in high stress, high demand environment while communicating clearly and effectively.
• Ability to establish and maintain professional boundaries, trusting and supportive relationships as well as provide inspiration and motivation to individuals transitioning toward recovery.
• Ability to adapt to changing priorities and circumstances while effectively managing time, workload, and competing responsibilities.
• Ability to utilize the Recovery Model, Evidence Based Practices and effectively engage with program participants.
• Ability to utilize various skills, methodologies, and approaches including motivational interviewing, trauma-informed care, harm reduction approach.
• Ability to navigate and access systems related to, but not limited to, food, cash, and other medical public benefits through Apple Health, DSHS, and Social Security Department.
• Ability to navigate and access systems, resources, and services related to Behavioral Health Services, medical and/or dental care, and basic needs.
• Ability to navigate and access systems, resources, and services related to emergency, transitional, supportive and permanent housing.
• Familiarity and knowledge of the Permanent Supportive Housing model and the Housing First approach, including principles of low-barrier access, harm reduction, and long-term housing stability for individuals with complex needs.
• Familiarity with trauma-informed care for people with complex needs.
• Familiarity and knowledge of best practices for alcohol/drug abuse treatment and prevention programs, mental health and developmental disabilities programs as well as with local social service agencies.
• Ability to write clear and concise clinical documentation, reports, and correspondence including documentation of all client interaction utilizing DAP style documentation within 24 hours.
• Ability to work collaboratively utilizing strong written and verbal communication skills as part of a multidisciplinary team while respectfully managing differences, opposing perspectives, opinions, and interests.
• Knowledge of and ability to recognize compassion fatigue and the need for self-care.
• Promote and champion the values of partnership, teamwork, compassion and integrity in all dealings within and outside of OHRS.

Working Conditions

• May require work in the community including jails, residential facilities, individual’s homes, and in an office environment.
• Regular use of fleet vehicles may be required for service provision in the region including transportation of participants in fleet vehicles. Use of personal vehicle may be required when not transporting participants.
• Regular, in person, predictable attendance is necessary for participant support and team engagement.
• May require availability to work flexible hours.
• Dress is professional and appropriate for community-based settings.
• Moderate physical activity is required. May be required to sit, stand, squat, walk short to moderate distances on uneven terrain, lift or move up to 25 lbs. Regular use of computer requiring typing and viewing monitors is required.
• May be required to walk distances in outdoor community-based setting to include uneven terrain and subject to weather conditions.