Justice Reentry Peer Support Specialist; Vaya's Eastern Region

LOCATION

Remote - must live in or near Vaya's Eastern North Carolina counties:
Rockingham, Rowan, Alamance, Caswell, Vance, Franklin, Chatham, Person, Granville, or Stokes. Incumbent must reside in North Carolina or within 40 miles of the NC border. This position requires travel in the community and visits to our members.

The primary purpose of this position is to serve individuals with serious mental illness (SMI) who are being released from a Department of Adult Corrections (DAC) facility and will be prioritized for re-entry coordination by both DAC and the applicable LME/MCO. This position will ensure communication between all parties, including DAC and related divisions (health services, re-entry, community supervision) and community behavioral and physical health providers.

The Justice Reentry Peer Support Specialist will coordinate and work parallel with the Justice Reentry Coordinator to ensure referrals are made to all necessary services including medication management, housing support, other social determinants of health needs, behavioral and physical healthcare, and benefits coordination. The Peer Support Specialist will assist with any follow up needs and coordination of services with individuals participating in the DAC Community Reentry Program.

Referrals will be made by DAC Social Workers directly to the Justice Reentry Coordinator and Peer Support staff approximately 90 days prior to release from incarceration.

This position will allow Local Management Entities/Managed Care Organizations (LME/MCOs) to interact with individuals with severe mental illness (SMI) who are within 90-days of releasing from a DAC (Division of Adult Corrections) Facility earlier on in the discharge planning process in an effort to better support positive outcomes upon their release from prison. This position will be responsible for providing case management and assistance to individuals referred in the process.

The Justice Reentry Peer Support Specialist will follow an individual indefinitely or until they qualify for tailored care management or other service providing a TCM equivalent, such as Assertive Community Treatment. The initial time period for this service will be ninety (90) days with the option to continue until needs are met as noted above.

This position will promote an efficient, clinically sound, and person-centered approach to supporting individuals through this process. Contact with community stakeholders is significant and the Peer Support Specialist is responsible for ensuring a high level of quality in customer service, including strong collaborative relationships with providers and key stakeholders (e.g. DAC, Hospitals, DSS, ACHs, behavioral health and physical health providers, internal departments, and natural supports).

This is a mobile position with work done in a variety of locations. The PSS staff spends a considerable amount of time in the field and completes required documentation/paperwork at an office location or in the employee's home (as applicable).

Managed Care Treatment Planning and Care Coordination:

• Possess knowledge of the needs of individuals with a mental illness, and substance use/addiction disorders and effectively work with all individuals with respect on a level that they can understand and relate to
• Ensures all State mandated tasks related to Dispositions and discharge are completed within benchmark time frames
• Ensures timely and thorough documentation of all efforts, both individual-specific and programmatically, as requested by Supervisor
• Coordinates with key providers and others in a collaborative approach to address needs of the individual and ensure appropriate treatment planning and evaluation
• Promotes person centered practices, including use of person-centered language and person-centered tools in planning
• Identifies gaps in services and intervenes to ensure that the individual receives appropriate care and discharge planning.
• Focuses on achieving positive outcomes for individuals, regardless of disposition status, including reduction in high risk events and inappropriate service utilization
• Ensures that services for the individual are coordinated across the Vaya Health system and with other systems, including primary care. Refers to other specialists for timely assessment as clinically indicated
• Provides support and direction for the individual and his/her treatment team to ensure quality service and community integration
• Educates others about various housing options/resources and how to access them

Collaboration:

• Partners with individuals/families, providers and community stakeholders, as applicable, to create solutions to issues/concerns, barriers to progress, etc.
• Works in partnership with other Vaya Health departments to address identified needs and opportunities to improve member outcomes
• Work is performed with considerable independence, with most work performed in the community and away from the office. Employee is familiar with…