Position Summary
The Clinical Assessor / Outpatient Therapist is responsible for conducting comprehensive behavioral health and substance use assessments, determining clinical needs and appropriate levels of care, developing individualized treatment recommendations, and providing outpatient therapy services when clinically appropriate. This position works with individuals experiencing substance use disorders, mental health conditions, co-occurring disorders, and related psychosocial needs.
The Clinical Assessor / Outpatient Therapist will utilize evidence-based clinical practices, person-centered approaches, and applicable ASAM and behavioral health standards to assess clients, develop treatment plans, provide therapeutic interventions, and coordinate services to support recovery and improved functioning.
The ideal candidate is clinically skilled, organized, compassionate, and able to independently complete assessments and clinical documentation while working collaboratively with the treatment team.
Essential Duties and Responsibilities
Clinical Assessments
Conduct comprehensive behavioral health and/or substance use assessments for new and existing clients.
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Complete biopsychosocial assessments and gather information regarding substance use, mental health, medical, family, social, legal, employment, housing, and recovery needs.
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Assess clients using appropriate clinical screening and assessment instruments.
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Identify presenting problems, strengths, risks, barriers to treatment, and recovery supports.
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Assess for co-occurring mental health and substance use disorders.
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Evaluate level-of-care needs and make clinically appropriate treatment recommendations.
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Utilize ASAM criteria and other applicable clinical standards when determining substance use treatment recommendations.
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Complete diagnostic impressions and clinical formulations within the scope of professional credentials and applicable regulations.
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Identify situations requiring referral for psychiatric, medical, crisis, withdrawal-management, residential, or other specialized services.
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Participate in reassessments and updates to clinical recommendations as client needs change.
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Outpatient Therapy
Provide individual outpatient therapy within the scope of licensure/certification and professional competency.
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Facilitate therapeutic interventions addressing substance use, mental health, trauma-related concerns, emotional regulation, coping skills, relapse prevention, interpersonal relationships, and behavioral change.
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Develop and implement individualized treatment plans in collaboration with clients.
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Monitor client progress toward treatment goals and modify interventions as clinically indicated.
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Utilize evidence-based and evidence-informed approaches such as Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), Person-Centered Therapy, Solution-Focused Therapy, relapse-prevention strategies, and other appropriate interventions.
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Provide co-occurring disorder treatment when within the clinician's scope of practice.
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Facilitate family or collateral sessions when clinically appropriate and authorized.
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Provide crisis intervention and safety planning within the scope of the position and organizational procedures.
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Treatment Planning and Care Coordination
Develop individualized, measurable treatment goals, objectives, and interventions.
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Collaborate with clients to establish person-centered recovery goals.
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Coordinate services with case managers, peer recovery specialists, medical providers, psychiatric providers, residential staff, and other members of the treatment team.
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Make appropriate referrals to community resources and higher or lower levels of care.
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Participate in treatment team meetings and case consultations.
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Assist clients with continuity of care and transitions between levels of treatment.
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Participate in discharge planning and aftercare coordination.
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Clinical Documentation
Complete assessments, treatment plans, progress notes, reassessments, discharge summaries, and other required clinical documentation accurately and within established timeframes.
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Maintain documentation that supports medical necessity and the services provided.
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Ensure clinical documentation is consistent with organizational policies, applicable Virginia DBHDS requirements, payer requirements, and professional standards.
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Maintain accurate and timely electronic health records.
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Document clinical interventions, client response, progress toward goals, barriers to treatment, and ongoing needs.
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Maintain confidentiality and comply with HIPAA and applicable privacy regulations.
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Compliance and Quality Assurance
Maintain knowledge of applicable Virginia behavioral health and substance use disorder regulations and standards.
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Follow organizational policies and procedures.
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Practice within the scope of the employee's license, certification, education, training, and experience.
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Maintain required professional credentials and continuing education.
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Participate in clinical supervision and consultation as required.
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Participate in quality assurance, utilization review, audits, and performance-improvement activities as assigned.
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Protect client confidentiality and maintain professional boundaries at all times.
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Required Qualifications
The specific credential requirements should be matched to the services being provided and Virginia regulatory requirements.
Preferred qualifications may include:
Master's degree in Counseling, Social Work, Psychology, or a related behavioral health field.
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Current Virginia clinical license or eligible credential appropriate to the position, such as LMHP, LPC, LCSW, LMFT, or other applicable credential.
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For substance use disorder services, CSAC, CSAC-A, or other applicable Virginia credential may be considered based on the duties and supervision structure.
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Experience conducting behavioral health and/or substance use assessments.
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Experience working with individuals with substance use disorders and/or co-occurring mental health conditions.
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Knowledge of ASAM levels of care and substance use treatment principles.
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Experience providing individual therapy is preferred.
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Preferred Experience
2+ years of experience in behavioral health, substance use disorder treatment, community mental health, residential treatment, or outpatient services.
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Experience conducting ASAM assessments or level-of-care assessments.
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Experience treating individuals with co-occurring disorders.
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Experience working in an ASAM 2.1, 2.5, 3.1, or outpatient treatment environment.
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Experience with electronic health records and electronic clinical documentation.
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Experience working with Medicaid and/or other behavioral health reimbursement systems.
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Physical and Work Requirements
Ability to work in an office, outpatient, residential, or community-based behavioral health environment as assigned.
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Ability to maintain extended periods of documentation and computer use.
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Ability to communicate effectively with clients, families, and interdisciplinary team members.
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Ability to respond appropriately to emotionally challenging and potentially crisis-oriented situations.
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Ability to maintain professional conduct and boundaries in all clinical settings.
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Employment Relationship
This job description describes the general nature and level of work performed by an individual assigned to this position. It is not intended to be an exhaustive list of all duties, responsibilities, qualifications, or requirements. Duties may be modified as organizational needs, client populations, regulatory requirements, and program services change.
Employees are expected to perform only those clinical services that are within their education, training, credentialing, scope of practice, and applicable Virginia laws and regulations.
