Crisis Follow-Up Specialist II in Owensboro, Kentucky at RiverValley Consulting Services

Job Summary:
The Crisis Follow-Up Specialist provides person-centered follow-up, care coordination, and service navigation for individuals following a behavioral health or substance-related crisis encounter, with a primary focus on individuals identified as having moderate-risk follow-up needs.
Working within the Crisis Services continuum, the Crisis Follow-Up Specialist conducts wellness contacts, supports connection to behavioral health and community services, assists with appointment navigation, coordinates with peer support services, and facilitates warm handoffs to appropriate providers. The position works collaboratively with crisis clinicians, peer support specialists, healthcare providers, and community partners to promote engagement, continuity of care, stabilization, and recovery-oriented outcomes.

Essential Functions:

• Carry moderate-risk post-crisis caseloads referred from 988, E/inpatient discharge, Mobile Crisis, SUD crisis/overdose risk, PSAP diversion, and other community stakeholders, as assigned.
• Initiate follow-up within 24 hours; document verbal/written consent; provide 90-day to 12-month structured follow-up.
• Engage individuals using trauma-informed, recovery-oriented, person-centered, and culturally responsive approaches.
• Implement Caring Contacts: iCare postcards, structured phone/text outreach, and low-demand check-ins.
• Assess follow-up needs and identify barriers that may interfere with successful connection to recommended behavioral health, substance use, medical, or community-based services.
• Assist individuals in understanding recommended services, available resources, treatment options, and next steps following a crisis episode.
• Facilitate connections and referrals to appropriate services, including outpatient behavioral health care, substance use treatment, medical services, peer support, and community-based resources.
• Provide appointment navigation, including assisting individuals with identifying appropriate providers, understanding referral requirements, coordinating appointments, and addressing barriers to attendance.
• Facilitate warm handoffs to behavioral health providers, healthcare organizations, peer support services, and other community partners to strengthen continuity of care.
• Coordinate with peer support specialists when peer-based engagement, recovery support, or service navigation would benefit the individual.
• Support transitions of care and work to reduce gaps in services that may contribute to repeated crisis episodes or unnecessary use of higher levels of care.
• Collaborate with crisis clinicians and other members of the interdisciplinary team regarding identified needs, risk and safety considerations, social determinants of health, service connections, and follow-up activities.
• Work collaboratively with behavioral health providers, medical providers, emergency departments, community organizations, and other partners to coordinate services.
• Serve as a liaison between individuals, families or natural supports when appropriate, providers, and community resources to facilitate successful service connection.
• Advocate for individual needs while promoting self-determination, dignity, empowerment, and appropriate professional boundaries.
• Maintain timely, accurate, and compliant documentation and data of outreach attempts, contacts, referrals, risk assessments and reassessments, service connections, warm handoffs, and follow-up outcomes in the electronic health record and other required systems per MOU and privacy requirements.
• Maintain effective communication with Crisis Services team members regarding follow-up status, barriers to care, service connections, and other relevant information.
• Adhere to agency policies, applicable licensing requirements, professional and ethical standards, HIPAA requirements, and applicable state and federal regulations.
• Participate in team meetings, trainings, case consultation, and quality-improvement activities related to crisis follow-up and continuity of care.
• Maintain knowledge of behavioral health, substance use, healthcare, peer support, and community resources available to individuals served by Crisis Services.
• Assist with Mobile Crisis Service delivery as needed and available.
• Perform additional responsibilities as needed to support Crisis Services program operations.

Education and Experience:

• Bachelor's degree in social work, psychology, or a related behavioral health field

Knowledge and Skills:

• Knowledge of mental health and substance use disorders, crisis services, harm reduction, and recovery-oriented approaches.
• Knowledge of community resources, behavioral health services, social service systems, and healthcare navigation.
• Ability to engage individuals following a crisis and establish rapport using person-centered, trauma-informed approaches.
• Ability to recognize barriers to treatment engagement and assist individuals in navigating services and resources.
• Ability to coordinate referrals, appointments, peer services, and warm handoffs across systems of care.
• Strong communication and interpersonal skills with the ability to collaborate effectively with individuals, families, providers, and community partners.
• Strong organizational, time-management, follow-through, and problem-solving skills.
• Ability to manage multiple follow-up contacts and priorities while completing required activities within established timeframes.
• Cultural humility and the ability to provide respectful services to individuals from diverse identities, backgrounds, and life experiences.
• Ability to maintain appropriate professional boundaries, confidentiality, and ethical standards.
• Proficiency with documentation, electronic health records, and coordinated communication across providers and systems.
• Valid driver's license.