ACT Peer Support & Care Coordination Specialist

REPORTS TO: Assertive Community Treatment Team Lead

STATUS: Exempt

MAIN FUNCTION:

The ACT Peer Support & Care Coordination Specialist provides recovery-oriented peer support and comprehensive care coordination services to individuals enrolled in the Assertive Community Treatment (ACT) program. Utilizing lived experience, this position promotes hope, engagement, self-advocacy, and recovery while assisting participants in accessing and coordinating behavioral health, physical health, and community-based services. As an integral member of the multidisciplinary ACT team, this position collaborates with psychiatric providers, nurses, therapists, case managers, primary care providers, hospitals, and community partners to promote whole-person wellness, reduce barriers to care, and support participants in achieving their individualized recovery goals.

DUTIES/RESPONSIBILITIES:

• Provide all services in accordance with the policies and procedures of Heartland Counseling Services, applicable professional codes of ethics, and all payor, licensing, accreditation, and governmental regulations.


• Attend and participate in all required ACT team meetings, daily organizational meetings, treatment planning meetings, clinical supervision, staff meetings, and required training.


• Complete all required Peer Support Specialist training and maintain certification as required.


• Document client services in accordance with agency policy, ACT standards, payer requirements, and regulatory guidelines.


• Utilize lived experience to inspire hope, promote recovery, and develop authentic, supportive relationships with participants.


• Share personal recovery experiences appropriately to encourage engagement, self-advocacy, and recovery.


• Assist participants in identifying strengths, developing recovery goals, and building resilience.


• Model and teach recovery-oriented coping skills, problem-solving techniques, wellness strategies, and self-management skills.


• Promote participant choice, empowerment, and self-determination throughout the recovery process.


• Assist participants in developing natural supports and increasing community integration.


• Advocate for and with participants by assisting them in preparing for appointments, meetings, court hearings, and other recovery-related activities.


• Coordinate behavioral health, physical health, dental, pharmacy, and specialty healthcare services for assigned ACT participants.


• Coordinate referrals and monitor follow-up with internal and external providers to ensure continuity of care.


• Collaborate with hospitals, primary care providers, specialists, pharmacies, managed care organizations, and community partners to promote integrated care.


• Coordinate transitions following psychiatric hospitalization, medical hospitalization, emergency department visits, incarceration, or other transitions in care.


• Assist participants with scheduling appointments, arranging transportation, obtaining medications, navigating insurance and benefits, and accessing community resources.


• Advocate for participants by identifying and addressing barriers related to social determinants of health.


• Promote whole-person wellness through coordination of behavioral health, physical health, preventive healthcare, and community support services.


• Collaborate with ACT nurses, psychiatric providers, therapists, and other team members to monitor participant progress and coordinate services.


• Participate in the development, implementation, and ongoing review of individualized treatment plans and recovery goals.


• Participate in shared ACT caseload responsibilities and provide services in participants' homes and community settings.


• Assist with outreach and engagement of participants who are difficult to engage in treatment.


• Assist the ACT Team in achieving quality indicators, health outcome measures, participant engagement goals, and other agency performance measures.


• Monitor referrals, follow-up activities, and care coordination tasks to promote successful outcomes.


• Maintain accurate and timely documentation in the electronic health record.


• Assist with the collection, maintenance, and reporting of participant information as requested for quality improvement and program monitoring.


• Provide crisis support to ACT participants and participate in the ACT on-call rotation as assigned.


• Perform other duties as assigned.

REQUIRED SKILLS/ABILITIES:

• Maintains confidentiality when working with clients.


• Demonstrates a strong commitment to recovery-oriented, person-centered care.


• Ability to utilize lived experience appropriately while maintaining professional boundaries.


• Strong verbal and written communication skills.


• Excellent interpersonal and relationship-building skills.


• Ability to work effectively within a multidisciplinary treatment team.


• Knowledge of behavioral health, substance use disorders, recovery principles, and community resources.


• Knowledge of integrated behavioral and physical healthcare concepts.


• Strong organizational, time management, and care coordination skills.


• Ability to effectively coordinate services across multiple providers and systems.


• Skilled in problem-solving, participant advocacy, and conflict resolution.


• Proficient in electronic health record documentation.


• Ability to establish positive working relationships with diverse populations and community partners.


• Must maintain Peer Support Specialist certification without disciplinary action.


• Possess a valid driver's license and an insurable driving record.

EDUCATION & EXPERIENCE:

• High school diploma or GED required.


• Certified Peer Support Specialist, or one continuous year as a current or former recipient of behavioral health treatment and eligible to obtain Peer Support Specialist certification.


• Experience providing peer support, care coordination, case management, or community-based behavioral health services preferred.


• Experience working within community mental health, ACT, or Certified Community Behavioral Health Clinic (CCBHC) settings preferred.

PHYSICAL REQUIREMENTS:

• Prolonged periods of sitting at a desk and working on a computer.


• Frequent community-based travel.


• Must be able to lift up to 15 pounds at times.