Behavioral Health Assessment Clinician

Behavioral Health Assessment Clinician

MAIN FUNCTION

The Behavioral Health Assessment Clinician serves as the primary clinical assessor for individuals entering services at Heartland Counseling Services. This position is responsible for conducting comprehensive mental health and substance use evaluations to ensure timely access to appropriate services.  The Behavioral Health Assessment Clinician serves as a clinical expert in assessment and diagnostic formulation, supporting the agency’s open access model through improved access to care, diagnostic accuracy, assessment quality, and service coordination. This position works closely with other programs to ensure clients are connected to the most appropriate level of care.

DUTIES & RESPONSIBILITIES

Assessment and Diagnostic Services

• Conduct comprehensive Initial Diagnostic Interviews (IDIs) and Substance Use Evaluations for individuals seeking behavioral health services. Meet same-day and scheduled assessment services through the agency's Open Access Clinic model.

• Formulate DSM-5-TR diagnoses and document medical necessity for treatment services.
• Determine appropriate levels of care and provide treatment recommendations.
• Administer, score, interpret, and document assessment instruments
• Complete accurate and timely clinical documentation in accordance with agency and regulatory standards.

Clinical Collaboration and Assessment Support

• Collaborate closely with Care Coordinators to facilitate successful transitions from assessment to ongoing services.
• Coordinate with Medical Records staff to obtain and review previous treatment records, assessments, discharge summaries, and other relevant clinical information to support diagnostic formulation and treatment recommendations.
• Contact referral sources, family members, guardians, healthcare providers, schools, probation officers, and other collateral contacts, as clinically appropriate and authorized, to gather information relevant to the assessment process.
• Complete internal referral documentation and provide clinical recommendations regarding appropriate program placement.

• Conduct drug screening collections and documentation in accordance with agency policies and procedures.
• Provide thorough orientation to clients regarding treatment processes, attendance expectations, service options, confidentiality, patient rights, and agency procedures.

• Participate in quality assurance and quality improvement activities as assigned.

Clinical Coverage and Program Support

• Provide assessment, group, crisis or clinical support coverage during therapist absences, vacancies, or periods of increased service demand.
• Offer consultation and support to interns, provisionally licensed clinicians, and other staff as assigned.
• Participate in community events, outreach, and engagement activities when requested.
• Participate in the agency’s after hours crisis on call rotation.
• Serve on at least one agency committee and support implementation of committee recommendations and action plans. 
• Provide services at other agency locations as assigned.
• Other duties as assigned.

Professional Development

• Maintain all required licenses, certifications, and credentials in active status.
• Attend clinical supervision, staff meetings, trainings, and continuing education activities as required.
• Maintain competency in current diagnostic practices, behavioral health assessment methods, and regulatory requirements.
• Pursue ongoing professional development related to mental health, substance use disorders, co-occurring disorders, assessment, diagnosis, and evidence-based practices.
• Demonstrate flexibility and openness to changes in clinical practice, regulations, and organizational needs.

REQUIRED SKILLS & ABILITIES

• Maintains ethics and confidentiality as dictated by professional standards and agency policy.
• Maintains state licensure and credentials in good standing without disciplinary action.
• Advanced knowledge of counseling theory, behavioral health assessment, and clinical practice.
• Strong knowledge of DSM-5-TR diagnostic criteria and diagnostic formulation.
• Knowledge of substance use disorders, co-occurring disorders, and level-of-care determinations.
• Ability to form therapeutic relationships with clients and establish rapport quickly.
• Ability to administer, score, interpret, and explain assessment tools and screening instruments.
• Strong interpersonal skills in working with diverse populations.
• Strong verbal and written communication skills.
• Ability to form cooperative and supportive working relationships with staff, community partners, referral sources, and other agencies.
• Ability to exercise sound clinical judgment and decision-making.
• Ability to manage competing priorities in a fast-paced Open Access Clinic environment.
• Strong organizational skills and attention to detail.
• Knowledge of Medicaid, CCBHC, CARF, and behavioral health documentation requirements.
• Possesses a valid driver's license and maintains an insurable driving record.

EDUCATION & EXPERIENCE

• Master's Degree in Counseling, Social Work, Marriage and Family Therapy, Psychology, or a related behavioral health field.
• Nebraska Licensed Independent Mental Health Practitioner (LIMHP); or
• Nebraska Licensed Mental Health Practitioner (LMHP) eligible to obtain LIMHP; or
• Nebraska LIMHP/(P)LADC dual licensure; and
• Experience conducting behavioral health assessments, diagnostic evaluations, and substance use evaluations.

PHYSICAL REQUIREMENTS

• Prolonged periods of sitting at a desk and working on a computer
• Must be able to lift up to 15 pounds at times.