Care Manager (Alamance County)
Company: Vaya Health
Location: Burlington
Posted on: November 14, 2024
Job Description:
LOCATION: Remote - must live in or near Alamance County, North
Carolina. GENERAL STATEMENT OF JOBThe 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. As further described below, essential job functions
of the Care Manager includes, but may not be limited to:
Utilization of and proficiency with
Vaya's Care Management software platform/ administrative health
record ("AHR")Outreach and engagementCompliance with HIPAA
requirements, including Authorization for Release of Information
("ROI") practicesPerforming 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
careAdherence to Medication List and Continuity of Care
processesParticipation in interdisciplinary care team meetings,
comprehensive care planning, and ongoing care
managementTransitional Care ManagementDiversion from institutional
placementThis 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
FUNCTIONSAssessment, 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.The assessment
process includes reviewing and transcribing member's current
medication and entering information into Vaya's Care Management
platform, which triggers the creation of a multisource medication
list that is shared back with prescribers to promote integrated
care.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.Ensure the Care Plan
includes specific services to address mental health, substance use,
medical and social needs as well as personal goalsEnsure the Care
Plan includes all elements required by NCDHHSUse information
collected in the assessment process to learn about member's needs
and assist in care planningEnsure members of the care team are
involved in the assessment as indicated by the member/LRP and that
other available clinical information is reviewed and incorporated
into the assessment as necessaryWork with members to identify
barriers and help resolve dissatisfaction with services or
community-based interventionsReviews 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. Help members refine and
formulate treatment goals, identifying interventions, measurements,
and barriers to the goalsEnsures that member/legally responsible
person ("LRP") is/are informed of available services, referral
processes (e.g., requirements for specific service), etc.Provides
information to member/LRP regarding their choice of service
providers, ensuring objectivity in the processWorks 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 involvedSupports and
may facilitate care team meetings where member Care Plan is
discussed and reviewedSolicits input from the care team and monitor
progressEnsures that the assessment, Care Plan, and other relevant
information is provided to the care team Reviews assessments
conducted by providers and consults with clinical staff as needed
to ensure all areas of the member's needs are addressedUpdates Care
Plans and Care Management assessment at a minimum of annually or
when there is a significant life change for the memberSupports and
assists with education and referral to prevention and population
health management programs.Works with the member/LRP and care team
to ensure the development of a Care Management Crisis Plan for the
member that is tailored to their needs and desires, which is
separate and complementary to the behavioral health provider's
crisis plan.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 careCoordinates Diversion efforts
for members at risk of requiring care in an institutional
settingConsults with care management licensed professionals, care
management supervisors, and other colleagues as needed to support
effective and appropriate member care.Collaboration, Coordination,
Documentation:Serves as a collaborative partner in identifying
system barriers through work with community stakeholders. Manages
and facilitates Child/Adult High-Risk Team meetings in
collaboration with DSS, DJJ, CCNC, school systems, and other
community stakeholders as appropriate. Works in partnership with
other Vaya departments to identify and address gaps in services/
access to care within Vaya's catchment.Participates in
cross-functional clinical and non-clinical meetings and other
projects as needed/ requested to support the department and
organization.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.Works with
Care Manager - LP and Care Manager Embedded - LP in participating
in other high risk multidisciplinary complex case staffing as
needed to include Vaya CMO/ Deputy CMO, Utilization Management,
Provider Network, and Care Management leadership to address
barriers, identify need for specialized services to meet client
needs within or outside the current behavioral health
system.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.Supports problem-solving and
goal-oriented partnership with member/LRP, providers, and other
stakeholders.Promotes member satisfaction through ongoing
communication and timely follow-up on any concerns/issues.Supports
and assists members/families on services and resources by using
educational opportunities to present information.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.Proactively and timely creates and monitors
documentation within the AHR to ensure completeness, accuracy and
follow through on care management tasks.Maintains electronic AHR
compliance and quality according to Vaya policy.Works with Care
Manager - LP and Care Manager Embedded - LP to ensure all clinical
and non-clinical documentation (e.g. goals, plans, progress notes,
etc.) meet all applicable federal, state, and Vaya requirements,
including requirements within Vaya's contracts with
NCDHHS.Participates in all required Vaya/ Care Management trainings
and maintains all required training proficiencies.Other duties as
assigned KNOWLEDGE, SKILL & ABILITIES:
Ability to express ideas
clearly/concisely and communicate in a highly effective
mannerAbility to drive and sit for extended periods of time
(including in rural areas)Effective interpersonal skills and
ability to represent Vaya in a professional mannerAbility to
initiate and build relationships with people in an open, friendly,
and accepting mannerAttention to detail and satisfactory
organizational skillsAbility to make prompt independent decisions
based upon relevant facts.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.A result and
success-oriented mentality, conveying a sense of urgency and
driving issues to closureComfort with adapting and adjusting to
multiple demands, shifting priorities, ambiguity, and rapid
changeThorough 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 researchUnderstanding 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. Experience and knowledge of the NC Medicaid program, NC
Medicaid Transformation, Tailored Plans, state-funded services, and
accreditation requirements are preferred.Ability to complete and
maintain all trainings and proficiencies required by Vaya, however
delivered, including but not limited to the following:BH I/DD
Tailored Plan eligibility and services Whole-person health and
unmet resource needs (ACEs, trauma-informed care, cultural
humility) Community integration (independent living skills;
transition and diversion, supportive housing, employment,
etc.)Components of Health Home Care Management (Health Home
overview, working in a multidisciplinary care team, etc.) Health
promotion (common physical comorbidities, self-management, use of
IT, care planning, ongoing coordination) Other care management
skills (transitional care management, motivational interviewing,
person-centered needs assessment and care planning, etc.) Serving
members with I/DD or TBI (understanding various I/DD and TBI
diagnoses, HCBS, Accessing assistive technologies, etc.) Serving
children (child-and family-centered teams, Understanding the
"System of Care" approach)Serving pregnant and postpartum women
with SUD or with SUD history Serving members with LTSS needs
(Coordinating with supported employment resources Job functions
with higher consequences of error may be identified, and
proficiency demonstrated and measured through job simulation
exercises administered by the supervisor where a minimum threshold
is required of the position. QUALIFICATIONS & EDUCATION
REQUIREMENTSBachelor's degree in a field related to health,
psychology, sociology, social work, nursing or another relevant
human services area is preferred. Serving members with BH
conditions: o Two (2) years of experience working directly with
individuals with BH conditionsServing members or recipients with
LTSS needso Two (2) years of prior LTSS and/or HCBS coordination,
care delivery monitoring and care management experience.o This
experience may be concurrent with the two years of experience
working directly with individuals with BH conditions, an I/DD, or a
TBI, described above-If graduate of a college or university with a
Bachelor's degree in Human Services, then incumbent must have two
years of full-time accumulated experience in mental health with
population served-If graduate of a college or university with a
Bachelor's degree is in field other than Human Services, then
incumbent must have four years of full-time accumulated experience
in mental health with population served-If a graduate of a college
or university with a Bachelor's Degree in Nursing and licensed as
RN, then incumbent must have four years of full-time accumulated
experience in mental health with population served. Experience can
be before or after obtaining RN licensure.-If graduate of a college
or university with a Master's level degree in Human Services,
although only one year of experience is needed to reach QP status,
the incumbent must still have at least two years of full-time
accumulated experience in mental health with the population
served
It is preferred for incumbents to also have experience working
directly with individuals with an I/DD or TBI.
*Must meet the criteria of being a North Carolina Qualified
Professional with the population served in 10A NCAC 27G .0104
Licensure/Certification Required:If Incumbent has a Bachelor's
degree in nursing and RN, incumbent must be licensed by the North
Carolina Board of Nursing to practice in the State of North
Carolina PHYSICAL REQUIREMENTS:Close visual acuity to perform
activities such as preparation and analysis of documents; viewing a
computer terminal; and extensive reading. Physical activity in this
position includes crouching, reaching, walking, talking, hearing
and repetitive motion of hands, wrists, and fingers.Sedentary work
with lifting requirements up to 10 pounds, sitting for extended
periods of time. Mental concentration is required in all aspects of
work. Ability to drive and sit for extended periods of time
(including in rural areas)
RESIDENCY REQUIREMENT: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.
DEADLINE FOR APPLICATION: Open Until Filled APPLY: Vaya Health
accepts online applications in our Career Center, please visit .
Vaya Health is an equal opportunity employer.
Keywords: Vaya Health, Winston-Salem , Care Manager (Alamance County), Executive , Burlington, North Carolina
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