To provide professional social work and case management services to children, youth, adults, and families served by the Department of Human Services through assessment, service planning, care coordination, monitoring, crisis intervention, and collaboration with community partners. Work is performed in accordance with applicable Wisconsin Statutes, Administrative Code, county policy, and professional standards. Employees in this classification may be assigned work in one or more program areas and are expected to perform the duties contained in the core job description, together with any program-specific addendum assigned to the position. Refer to “Children’s Long-Term Support (CLTS) Addendum”, “Comprehensive Community Services (CCS) Addendum”, “Coordinated Services Team (CST) Addendum”, “Children’s Protective Services and Youth Justice Addendum”, “Behavioral Health and Crisis Services Addendum”, and “School-Based Services Social Worker Addendum”.

This assignment provides service facilitation and case management within the Comprehensive Community Services program for individuals across the lifespan with mental health and/or substance use service needs. The employee fulfills requirements of the CCS Service Facilitator role as outlined in Wisconsin Administrative Code DHS 36 and is responsible for assessment, service planning, team coordination, documentation, monitoring, and coordination of psychosocial rehabilitation and recovery-oriented services.

This assignment serves children and youth with medical, physical, developmental, emotional, and mental health support needs through the Children's Long-Term Support Program. The employee functions as the county's service coordinator/service facilitator for assigned CLTS participants and is responsible for planning, arranging, coordinating, monitoring, and documenting services in accordance with applicable Wisconsin Statutes, including chapters 46 and 49, Medicaid and HCBS waiver requirements, and county and program standards.

• This list of duties is not to be construed as all-inclusive and may be modified as need requires. Special duty assignments will occur.
• Accept requests and referrals for agency services and determine the appropriate program, level of response, and next steps based on presenting needs, available information, and applicable program requirements.
• Conduct comprehensive, strength-based assessments through interviews, home visits, collateral contacts, record review, and consultation with providers, schools, law enforcement, courts, and other involved parties, as appropriate.
• Identify needs, risks, strengths, and service barriers; develop, implement, and update service plans in collaboration with the client, family, caregiver, and other supports.
• Coordinate and monitor services to ensure services are authorized when required, delivered in a timely manner, responsive to identified needs, and consistent with program goals, safety requirements, and available resources.
• Explain the scope of services, client rights and responsibilities, confidentiality expectations, mandatory reporting obligations, and the consequences of non-compliance with service plans or court orders when applicable.
• Maintain complete, accurate, and timely case records, assessments, plans, progress notes, correspondence, data entry, billing documentation, and reports in accordance with statute, administrative code, program standards, county policy, and professional practice expectations.
• Prepare reports, summaries, court-related documentation, referrals, and other written materials as necessary and appropriate; testify in court or at hearings when required.
• Provide or coordinate crisis response, safety planning, and follow-up services within the scope of assigned programs, training, and authority.
• Collaborate with families, providers, schools, medical personnel, law enforcement, Corporation Counsel, the District Attorney, courts, and community partners to support safety, stability, permanency, recovery, and well-being.
• Participate in supervision, staffings, team meetings, committees, trainings, and professional development activities; maintain working knowledge of program laws, policies, standards, and best practices.
• Adhere to approved social work principles, methods, and practices, including the NASW Code of Ethics, and maintain confidentiality in dealing with all pertinent information.
• Perform other duties as assigned or required. Under the direction of the supervisor, this position may at times be required to work overtime hours or shifts.
• Fulfill requirements of Service Facilitator for the Comprehensive Community Services program as outlined in Wisconsin Administrative Code DHS 36 and related county, state, and federal standards.
• Accept referrals and requests for service; assist with screening, intake, orientation, and transition processes for CCS participants and explain program scope, service array, participant rights and responsibilities, and recovery-focused expectations.
• Conduct comprehensive, strength-based assessments through interviews, home visits, collateral contacts, and review of records to identify service needs, functional limitations, strengths, risks, preferences, and recovery goals.
• Develop, coordinate, and update individualized recovery and service plans in collaboration with the participant, family or supports when appropriate, service providers, and other involved systems.
• Coordinate and participate in recovery team meetings with the goal of bringing teams together to work collaboratively with and for consumers; document decisions, responsibilities, service changes, and follow-up tasks.
• Arrange, authorize as applicable, and monitor services designed to support psychosocial rehabilitation, symptom management, stability in the community, recovery, and improvement in functioning.
• Assess ongoing consumer needs while developing and updating service plans to address needs; coordinate and monitor ongoing delivery of services to consumers and respond to barriers, engagement concerns, non-compliance, health and safety issues, and gaps in service delivery.
• Provide community services per Wisconsin Statutes, court policies, and requirements of program, state, or federal guidelines when applicable to the assigned caseload.
• Maintain documentation that meets professional practice, billing expectations, and program standards, including progress notes, service plans, assessments, team meeting documentation, contacts, and other records necessary for audit readiness and billing compliance.
• Prepare correspondence, reports, summaries, and records as necessary and appropriate and communicate with providers, hospitals, law enforcement, and other stakeholders in support of coordinated service delivery.
• Collaborate with internal county programs and external providers to coordinate behavioral health treatment, substance use services, medication supports, housing supports, employment or education supports, and other services consistent with participant needs and program scope.
• Participate in training, supervision, utilization review, quality assurance, and program development activities necessary to maintain compliance with DHS 36 and county standards.
• Accept and process requests, referrals, and transfers for the CLTS Program; assist families in understanding program eligibility, service availability, timelines, and the service coordination process.
• Conduct and document strength-based assessments through interviews, home visits, record review, and collateral contacts to identify the child's and family's needs, strengths, risks, functional limitations, and support needs.
• Participate in or coordinate activities necessary to determine and maintain eligibility for CLTS services, including gathering information needed for screening, enrollment, redetermination, and related program requirements.
• In collaboration with the child, parents or caregivers, providers, and natural supports, determine the range and type of needed services and develop, implement, and update the individualized service plan.
• Coordinate authorized supports and services for children and youth based on assessed needs; monitor service delivery, provider performance, utilization, health and safety concerns, outcomes, and family satisfaction, and take corrective action when needed.
• Coordinate and facilitate team meetings with the goal of bringing people together to collaboratively work with and for families, including schools, therapists, medical providers, respite providers, and other involved systems.
• Maintain regular contact with families and providers through home visits, office contacts, phone contacts, and other communication methods to assess ongoing needs and assure that services continue to meet program and family goals.
• Explain the scope of services and the family's rights and responsibilities in relation to the use of services, including free choice of providers where applicable, grievance or appeal processes, mandatory reporting obligations, and limits of county authority.
• Prepare correspondence, records, referrals, service authorizations, summaries, and reports as necessary and appropriate; maintain documentation that meets professional practice, billing expectations, Medicaid requirements, and CLTS program standards.
• Monitor health and safety issues affecting enrolled children and youth; respond to identified concerns, document actions taken, and coordinate corrective planning or referrals as appropriate.
• Participate in required state, regional, county, and program meetings, trainings, quality assurance activities, and other tasks necessary to maintain compliance with CLTS requirements and best practice standards.

On-Call / Access Responsibilities

• The Pepin County Department of Human Services is committed to providing timely support for emergencies and urgent service needs through our on-call and ACCESS systems,
• Available 24 hours a day, 365 days a year. Our ACCESS program operates during regular business hours, while our On-Call service is ready to assist outside of these hours.
• Participation in on-call and/or ACCESS rotation is based on assignment, training, departmental need, and supervisory direction. Not all employees in this classification are required to participate in the on-call or ACCESS pool.
• When assigned, on-call and ACCESS duties may include screening referrals, responding to emergencies, completing safety or crisis assessments, coordinating emergency services, consulting with law enforcement or other responders, and documenting actions taken in compliance with applicable statutes, administrative code, and county policy.

• Bachelor's degree in Social Work or closely related human services field; additional education, certification, or licensure may be required depending on assignment and wage scale placement.
• Knowledge of social work theory and methods, family systems, human development and behavior, trauma, crisis intervention, and community-based service delivery.
• Knowledge of and ability to interpret and administer applicable federal, state, and county laws, rules, regulations, standards, and policies governing direct services programs.
• Valid driver's license and/or available means of transportation required; appointment is conditional upon successful completion of required background checks.
• Maintain personal auto insurance that fully meets the coverage limits mandated by Pepin County.
• Social Work certification is preferred but not required.
  
• Knowledge of the functions, procedures, organization, policies, and regulations governing the administration of the Children's Long-Term Support Program.
• Knowledge of child development, childhood disorders, disabilities, family systems, and the service needs of children and youth with special needs and their families.
• Knowledge of the functions, procedures, organization, policies, and regulations governing the administration of the Comprehensive Community Services Program.
• Knowledge of recovery concepts, psychosocial rehabilitation, mental health and substance use service systems, and services provided to individuals across the lifespan in a wraparound or team-based approach.

·         Ability to establish and maintain effective working relationships with clients, families, providers, supervisors, peers, and the public.

·         Ability to communicate clearly and effectively, both orally and in writing, and to prepare accurate documentation suitable for administrative, billing, and court purposes.

·         Ability to apply critical thinking, professional judgment, de-escalation skills, and sound decision-making in routine and urgent situations.

·         Ability to navigate and operate a computer and use multiple software systems, phone, copier, scanner, and other office technology.

·         Ability to facilitate recovery team meetings, manage multiple provider relationships, and coordinate service planning that is participant-driven and recovery-oriented.

·         Ability to maintain compliant documentation suitable for billing, audit, and program review.

·         Ability to coordinate complex services across multiple providers and systems while maintaining a family-centered and strengths-based approach.

·         Ability to maintain complete and compliant documentation and to monitor services for health, safety, utilization, and quality concerns.

• 10 Paid Holidays
• Paid Time Off -available for use upon hire
• Wisconsin Retirment System with county match
• Health Insurance 80% of plan paid by the county
• Life Insurance Plan paid the county
• Income Continuation Insurance -no cost to employee

Other Benefits Available:

• Dental Insurance
• Vision Insurance
• Additional Life Insurance
• Disablity Insurance
• Critcial Illness and Cancer Insurance
• Accident Insurance
• Medical Flex Spending Account
• Dependent Care Flex Spending Account
• HSA Account
• Employee Achievement  Program-REALiving

Physical and Environmental Factors

• Ability to work under conditions which require exposure to environmental factors such as irate individuals, intimidation, odors, pets, traffic hazards, and disease. This exposure may cause some discomfort and presents risk of injury.
• Ability to operate and maneuver machinery requiring simple but continuous adjustments such as motor vehicle, computer, copier/fax machines.
• Ability to coordinate eyes, hands, feet, and limbs in performing movements requiring moderate skill, such as typing.
• Ability to exert light physical effort in sedentary to light work, but which may involve some lifting, carrying, pushing, and pulling.
• Ability to recognize and identify degrees of similarities or differences between characteristics of colors, shapes, sounds, and odors associated with job-related objects, materials, and tasks

Application forms may be obtained at: www.co.pepin.wi.us or by contacting Pepin County Personnel Department at 715-672-8704. Completed applications, resumes, and cover letters should be emailed to mweiss@co.pepin.wi.us or mailed to PO Box 39, Durand, WI 54736.