Job Description ? Lead Therapist
Position Overview:
The Therapist is supervised by the Clinical Director.
As a Lead Therapist at PH Wellness, you will be a vital part of our dedicated clinical team focused on providing high-quality compassionate care to all PH Wellness clients. Under the supervision of the clinical director, you will be responsible for providing clinical support in the detox/residential social model program and per the Board of Behavioral Sciences (BBS). The Primary Therapist is responsible for care, treatment, and services and record of care, treatment, and services related to clinical.
The clinical staff do not prescribe or administer medications.
The responsibility of the position requires that the individual assist residents in recognizing that drugs and alcoholism is a disease and therapist is to motivate residents to actively participate in their own recovery process, assisting them with learning skills, and gain knowledge to improve their lives so they may live without drugs or alcohol. They will maintain positive, professional boundaries, relationships with residents, staff, physicians, visitors and other staff, and they will collect information about residents using techniques such as testing, interviewing, discussion, and observation. They will maintain confidentiality of records relating to residents' treatment, and they will prepare and maintain all required treatment records and reports. They will counsel residents individually and in group sessions, to assist in overcoming dependencies, maladjustment aiding them in making positive changes, and collaborate with other staff members to perform clinical assessments. They will attend treatment team staff meetings, and act as resident advocate to coordinate required services or to resolve emergency problems in crisis situations. They will perform ongoing evaluation of residents' physical or mental condition based on review of resident, and conduct one on ones with residents, meet with families and maintain resident Electronic Health Records (EHR) documents in resident file per the APA ethical codes, organization policies, state and federal regulations, and the Joint Commission standards.
Competencies and Abilities
- Identify symptoms of alcohol or drug abuse and withdrawal (PAWS)
- Gather, interpret, report, and use information to support resident detox
- Determines when a referral is needed and how to coordinate
- Can collaborate with residents to create treatment plans
- Can perform screenings and assessments regarding alcohol and drugs and mental health
- Abides by ethical codes or APA and CCAPP
Clinical Leadership
- Provide clinical leadership and support to treatment team
- Serve as a clinical resource for therapists regarding client presentation, treatment interventions, documentation and treatment planning.
- Assist the Clinical Director with monitoring the quality and consistency of clinical services.
- Participate in clinical staffing, treatment team meetings, case consultations, and program development.
- Assist with identifying clinical concerns and communicating significant changes in client status to the appropriate members of the treatment team.
- Support implementation of evidence-based and trauma-informed treatment practices.
Direct Client Care
- Conduct individual, group, and family therapy within the scope of professional licensure and training.
- Complete clinical assessments and gather information necessary to identify client strengths, needs, risks, and treatment priorities.
- Develop, implement, and update individualized treatment plans.
- Provide therapeutic interventions appropriate to the client's diagnosis, substance use history, level of care, and treatment goals.
- Facilitate psychoeducational, process, recovery, relapse-prevention, coping skills, and other clinically appropriate groups.
- Monitor client progress and identify barriers to treatment participation and recovery.
- Assis clients with developing coping skills, relapse-prevention strategies, recovery supports and discharge goals.
Documentation and Clinical Records
- Ensure timely, accurate, objective and clinically appropriate documentation
- Review treatment plans, progress notes, group documentation, discharge summaries, and other clinical records as assigned.
- Ensure documentation supports medical necessity and accurately reflects the services provided and the client's response to treatment.
- Assist therapists with improving documentation quality when deficiencies are identified.
- Complete documentation in the facility's electronic medical record system, including KIPU, within required timeframes.
- Participate in treatment team meetings with medical, case management, and support staff.
- Communicate relevant clinical information regarding client progress, risks, behavioral concerns, treatment barriers and discharge planning.
- Collaborate with medical staff regarding changes in client presentation that may require additional assessment or intervention.
- Promote continuity of care from detoxification through residential treatment and discharge.