LOCATION: Remote – must live in or near Stokes County, North Carolina. The position must live in North Carolina or within 40 miles of the North Carolina border. This position requires travel.
GENERAL STATEMENT OF JOB
The Care Manager is responsible for providing proactive intervention and coordination of care to eligible Vaya Health members and recipients (“members”) to ensure that these individuals receive appropriate assessment and services. The Care Manager works with the member and care team to alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, linkage and/or coordination of services needed by the member across the MH, SU, intellectual/ developmental disability (“I/DD”), traumatic brain injury (“TBI”) physical health, pharmacy, long-term services and supports (“LTSS”) and unmet health-related resource needs networks. Care Managers support and may provide transition planning assistance to state, and community hospitals and residential facilities and track individuals discharged from facility settings to ensure they follow up with aftercare services and receive needed assistance to prevent further hospitalization. This is a mobile position with work done in a variety of locations, including members’ home communities. The Care Manager also works with other Vaya staff, members, relatives, caregivers/ natural supports, providers, and community stakeholders. Essential job functions of the Care Manager include, but may not be limited to:
- Utilization of and proficiency with Vaya’s Care Management software platform/ administrative health record (“AHR”)
- Outreach and engagement
- Compliance with HIPAA requirements, including Authorization for Release of Information (“ROI”) practices
- Performing Health Risk Assessments (HRA): a comprehensive bio-psycho-social assessment addressing social determinants of health, mental health history and needs, physical health history and needs, activities of daily living, access to resources, and other areas to ensure a whole person approach to care
- Adherence to Medication List and Continuity of Care processes
- Participation in interdisciplinary care team meetings, comprehensive care planning, and ongoing care management
- Transitional Care Management
- Diversion from institutional placement
This position is required to meet NC Residency requirements as defined by the NC Department of Health and Human Services (“NCDHHS” or “Department”). This position is required to live in or near the counties served to effectively deliver in-person contacts with members and their care teams.
ESSENTIAL JOB FUNCTIONS
Assessment, Care Planning, and Interdisciplinary Care Team:
- Ensures identification, assessment, and appropriate person-centered care planning for members.
- Links members with appropriate and necessary formal/ informal services and supports across all health domains (i.e., medical, and behavioral health home)
- Meets with members to conduct the HRA and gather information on their overall health, including behavioral health, developmental, medical, and social needs.
- Administer the PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings within their scope based on member’s needs. The Care Manager uses these screenings to provide specific education and self-management strategies as well as linkage to appropriate therapeutic supports.
- Supports the care team in development of a person-centered care plan (“Care Plan”) to help define what is important to members for their health and prioritize goals that help them live the life they want in the community of their choice.
- Reviews clinical assessments conducted by providers and partners with Care Manager - LP and Care Manager Embedded - LP for clinical consultation as needed to ensure all areas of the member’s needs are addressed.
- Ensures that member/legally responsible person (“LRP”) is/are informed of available services, referral processes (e.g., requirements for specific service), etc.
- Works in an integrated care team including, but not limited to, an RN (Registered Nurse) and pharmacist along with the member to address needs and goals in the most effective way ensuring that member/LRP have the opportunity to decide who they want involved.
- Provides crisis intervention, coordination, and care management if needed while with members in the community.
- Supports Transitional Care Management responsibilities for members transitioning between levels of care.
- Coordinates Diversion efforts for members at risk of requiring care in an institutional setting.
- Participates in routine multidisciplinary huddles including RN, Pharmacist, M.D. to present complex clinical case presentation and needs, providing support to other CMs (Care Manager) and receiving support and feedback regarding CM interventions for clients’ medical, behavioral health, intellectual /developmental disability, medication, and other needs.
- Monitors provision of services to informally measure quality of care delivered by providers and identify potential non-compliance with standards.
- Ensures the health and safety of members receiving care management, recognize and report critical incidents, and escalate concerns about health and safety to care management leadership as needed.
- Promotes member satisfaction through ongoing communication and timely follow-up on any concerns/issues.
- Verifies member’s continuing eligibility for Medicaid, and proactively responds to a member’s planned movement outside Vaya’s catchment area to ensure changes in their Medicaid county of eligibility are addressed prior to any loss of service.
- Maintains electronic AHR compliance and quality according to Vaya policy.
KNOWLEDGE, SKILL & ABILITIES
- Ability to express ideas clearly/concisely and communicate in a highly effective manner.
- Effective interpersonal skills and ability to represent Vaya in a professional manner.
- Attention to detail and satisfactory organizational skills.
- Well-developed capabilities in problem solving, negotiation, arbitration, and conflict resolution, including a high level of diplomacy and discretion to effectively negotiate and resolve issues with minimal assistance.
- Thorough knowledge of standard office practices, procedures, equipment, and techniques and intermediate to advanced proficiency in Microsoft office products (Word, Excel, Power Point, Outlook, Teams, etc.), and Vaya systems, to include the care management platform, data analysis, and secondary research.
- Understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) within their scope and have considerable knowledge of the MH/SU/IDD/TBI service array provided through the network of Vaya providers.
QUALIFICATIONS & EDUCATION REQUIREMENTS
Bachelor’s degree required, preferably in a field related to health, psychology, sociology, social work, nursing or another relevant human services area.
- Serving members with BH conditions:
- Two (2) years of experience working directly with individuals with BH conditions.
- Serving members with LTSS needs
- Two (2) years of prior Long-term Services and Supports (LTSS) and/or Home Community Based Services (HCBS) coordination, care delivery monitoring and care management experience.
PHYSICAL REQUIREMENTS
- Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
- Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.
SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.
Vaya Health is an equal opportunity employer.