IHT Clinician

LATINO COUNSELING CENTER INC - 2.2

Springfield, MA Job Details Full-time $60,000 - $75,000 a year 4 hours ago Qualifications Electronic health records (EHR) management Full Job Description

LATINO COUNSELING CENTER, INC. LICENSED / LICENSE-ELIGIBLE CBHI IN-HOME THERAPY

(IHT)

CLINICIAN

Department Children's Behavioral Health Initiative (CBHI) - In-Home Therapy (IHT) Employment Status Full-Time / as stated in individual offer letter Reports To Clinical Supervisor / Clinical Director / Program Director, as assigned Primary Service Setting Home, community, office, telehealth when authorized, and other approved settings On-Call Participation in rotating on-call coverage through 8:00 p.m., as scheduled 1. Overview Latino Counseling Center, Inc. (LCC) has served English- and Spanish-speaking communities since 2018. LCC is committed to providing culturally responsive, confidential, ethical, clinically appropriate, and family-centered behavioral-health services. 2. Position Summary The CBHI In-Home Therapy (IHT) Clinician provides intensive, family-centered behavioral-health services to youth and families. The clinician is responsible for assessment, treatment planning, therapeutic intervention, risk and safety assessment, care coordination, family engagement, transition/discharge planning, and complete clinical documentation. The clinician must practice only within verified education, licensure status, supervision requirements, payer requirements, and assigned scope.

DOCUMENTATION IS A CORE JOB FUNCTION, NOT AN OPTIONAL ADMINISTRATIVE TASK.

Services that are not timely, accurate, clinically supported, authorized when required, and properly documented may create client-safety, continuity-of-care, payer, audit, and billing risk. The clinician is responsible for completing documentation within the timelines below or any shorter deadline required by a payer, contract, regulation, or written LCC policy. 3. Essential Clinical Responsibilities Provide intensive home- and community-based therapy to youth and families using clinically appropriate and culturally responsive interventions. Complete comprehensive clinical assessment and formulation; identify strengths, needs, risks, functional impairment, family/system factors, and medical necessity as applicable. Develop measurable, individualized treatment goals and interventions with the youth/family and involved team members. Assess suicide risk, self-harm, violence risk, abuse/neglect, exploitation, substance-use concerns, and other safety issues; follow mandated-reporting and crisis-escalation procedures. Develop, review, and update safety/crisis plans when clinically indicated and ensure the family understands how to use them. Coordinate with caregivers, schools, PCPs, psychiatry, outpatient providers, state agencies, care coordinators, crisis services, and other authorized supports. Participate in supervision, case consultation, utilization review, QA, audits, training, staff meetings, corrective-action activities, and re-audits as assigned. Maintain professional boundaries, informed consent, confidentiality, HIPAA compliance, and minimum-necessary use of PHI. Provide clinically appropriate transition/discharge planning and timely handoff of open safety, authorization, treatment, and follow-up needs. Maintain required licensure/eligibility, credentials, trainings, CANS certification when applicable, and payer/program requirements. 4. Mandatory Documentation Timelines The following are LCC job-performance expectations for this position unless a controlling payer/program requirement requires an earlier deadline. The clinician must know and follow the shortest applicable deadline.

Document / Task

LCC Deadline Minimum Expectation Escalation if At Risk Progress / Service Note Within 24 hours of the service; same day whenever feasible Accurate date, start/end or duration as required, location/modality, participants, intervention, response, progress toward goals, risk/safety, plan/next step, and required signature/credentials. Notify supervisor before deadline when a documented operational or clinical barrier prevents completion. Initial Comprehensive Assessment (CA) Complete and submit within 21 calendar days of intake/admission, or earlier if payer/program rules require Assessment must support clinical formulation, diagnosis when within scope, functional needs, medical necessity, risk, strengths, family/system context, and treatment recommendations. Supervisor/QA escalation before day 21 if incomplete. Initial Treatment Plan Complete and obtain required signatures within 21 calendar days of intake/admission, or earlier if required Goals must be measurable and linked to assessed needs; interventions, frequency/intensity, responsible parties, and discharge/transition considerations must be clear. Supervisor/QA escalation before day 21 if signatures or required elements remain outstanding. CANS Complete by the applicable CBHI/payer deadline and before any required due date shown in LCC tracking systems CANS must be current, clinically consistent with the assessment/treatment plan, and completed by a certified user when required. Escalate no later than 7 calendar days before expiration/due date if completion is at risk. CA / Treatment Plan / CANS Updates Complete before the existing document expires or by the payer/program due date; do not allow a known required update to lapse Update must reflect current presentation, progress, risk, medical necessity, goals, interventions, and level-of-care needs. Escalate at least 7 days before due date if barriers exist.

Safety / Crisis

Plan At intake when required or clinically indicated; immediately when a new significant safety risk is identified Plan must be individualized, accessible to the family, clinically current, and reviewed after significant risk changes or crisis events. Immediate supervisor/crisis escalation for urgent risk; do not delay for routine documentation workflow. Care Coordination / Collateral Documentation Within 24 hours of the coordination activity when it is part of the clinical record Document purpose, authorized participants, relevant information exchanged, clinical impact, decisions, and follow-up. Escalate if consent/authorization or role boundaries are unclear.

Authorization / Continued

-Stay Support Submit clinical information early enough to avoid preventable authorization lapse and by internal/payer deadline Clinician must provide accurate clinical support requested for authorization and respond promptly to utilization-review needs. Immediately notify supervisor/authorization staff of any risk of lapse or service interruption.

Incident / Safety

/ Mandated Report Documentation Immediately follow emergency/mandated-reporting procedures; complete required LCC documentation the same business day whenever feasible Clinical safety action comes first. Document facts, actions taken, notifications, consultation, and follow-up without speculation. Immediate supervisor/Clinical Director/Compliance escalation as required.

Discharge / Transition

Documentation Begin planning before discharge; complete final clinical documentation promptly and no later than LCC/payer deadline Reason for discharge, progress, remaining needs/risks, medications/providers when relevant, referrals, follow-up, and continuity-of-care plan. Escalate before case closure if required handoff or documentation is incomplete. 5. Documentation Quality Standards Document contemporaneously and truthfully. Never backdate, fabricate, copy forward inaccurate information, or alter a record solely to make a service billable. Every billed service must be supported by documentation that matches the actual service, duration/units, rendering provider, participants, location/modality, intervention, and authorization requirements. Documentation must demonstrate the clinical purpose of the service and its relationship to the assessment and treatment plan. If an error is discovered after signing, use the approved amendment/addendum/correction process. Never delete or conceal the original record when the system or policy requires preservation. Late entries must be identified as late entries and completed according to LCC policy; repeated late documentation may result in performance management. Clinicians are responsible for reviewing their own documentation queues, due-date trackers, authorizations, treatment-plan dates, CANS dates, signatures, and assigned corrective actions. No clinician may ask another person to sign, attest, or document work the other person did not perform or supervise as required. 6. Productivity and 40-Hour Workweek Expectations For full-time clinicians, the workweek includes direct/billable clinical services plus the administrative and clinical-support functions necessary to perform the job, including documentation, supervision, meetings, care coordination, training, authorization support, travel where applicable, QA, and required follow-up. The employee's individual offer letter/productivity agreement controls the specific billable-hour target and any approved over-productivity arrangement.

PRODUCTIVITY NEVER OVERRIDES MEDICAL NECESSITY, CLIENT SAFETY, AUTHORIZATION, DOCUMENTATION QUALITY, OR BILLING INTEGRITY. 7.

Supervision, QA and Audit Accountability Attend all required individual and group supervision and come prepared to discuss clinical risk, treatment progress, documentation, authorizations, and barriers. Respond to QA/audit corrections by the assigned deadline and provide evidence of completion when requested. Participate in competency remediation, retraining, corrective action, or re-audit when performance or compliance concerns are identified. Immediately report suspected duplicate billing, unsupported time/units, authorization problems, documentation integrity concerns, privacy incidents, or other compliance concerns through LCC channels. Good-faith reporting is expected. Clinicians must not retaliate against or discourage another person from reporting a safety, quality, privacy, billing, or compliance concern. 8. Qualifications Master's degree in Human Services, Clinical Mental Health Counseling, Social Work, Psychology, or a related field meeting applicable program/payer requirements. LICSW, LMHC, other applicable Massachusetts credential, or documented license-eligible status consistent with the assigned role. Valid Massachusetts license when the assigned functions require independent licensure, or active progress on the approved licensure pathway when hired as license-eligible. Minimum of three (3) years of relevant clinical experience, unless LCC approves another qualification structure consistent with program/payer requirements. Bilingual Spanish preferred. Ability to use an electronic health record, meet documentation deadlines, communicate professionally, travel to community/home settings as required, and respond appropriately to clinical risk. 9. On-Call Responsibilities Participate in rotating on-call coverage through 8:00 p.m. as scheduled. The clinician must follow LCC escalation procedures, document clinically relevant contacts, and communicate urgent safety or continuity-of-care issues to the appropriate supervisor/crisis resource. 10. Performance Accountability Failure to meet documentation, supervision, quality, safety, productivity, attendance, credentialing, authorization-support, or compliance expectations may result in coaching, retraining, increased supervision, corrective action, performance improvement planning, restriction of duties, or other action consistent with LCC policy and applicable law. A single deadline issue will be evaluated in context; repeated, avoidable, or unreported deficiencies may be treated as a performance concern. 11. Employee Acknowledgment I acknowledge that I have reviewed this job description and understand that timely and accurate clinical documentation is an essential function of the IHT Clinician position. I understand that I am responsible for monitoring my assigned clinical and documentation deadlines and for escalating barriers before a deadline is missed whenever reasonably possible. Employee Name ________________________________________ Employee Signature ________________________________________ Date ________________ Supervisor / Director ________________________________________ Supervisor Signature ________________________________________ Date ________________