LOCATION: Remote - must live in or near Jackson, Swain, or Graham County, North Carolina. Incumbent in this role must live in North Carolina or within 40 miles of the NC border. This position requires travel.
GENERAL STATEMENT OF JOB
The Innovations Care Manager (Innovations CM) 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 Innovations CM 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. Innovations CMs 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 Innovations CM also works with other Vaya staff, members, relatives, caregivers/natural supports, providers, and community stakeholders. As further described below, essential job functions of the Innovations CM 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 Innovations CM 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.
- Ensures that member/legally responsible person ("LRP") is/are informed of available services, referral processes, 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.
- Ensures that the assessment, care plan and other relevant information is provided to the care team.
- Update Care Plans and Care Management assessment at a minimum of annually or when there is a significant life change for the member.
- Provides crisis intervention, coordination, and care management if needed while with members in the community.
Support Monitoring/Coordination, Documentation and Fiscal Accountability:
- Serves as a collaborative partner in identifying system barriers through work with community stakeholders.
- 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.
- Ensures the health and safety of members receiving care management, recognizes and reports critical incidents, and escalates concerns about health and safety to care management leadership as needed.
- Ensure that services are monitored (including direct observation of service delivery) in all settings at required frequency and for compliance with standards.
- Ensure accurate/timely submission of Service Authorization Requests (SARS) for all Vaya funded services/supports.
KNOWLEDGE, SKILL & ABILITIES
- Ability to express ideas clearly/concisely and communicate in a highly effective manner
- Ability to drive and sit for extended periods of time (including in rural areas)
- Effective interpersonal skills and ability to represent Vaya in a professional manner
- Attention to detail and satisfactory organizational skills
- Ability to make prompt independent decisions based upon relevant facts
- 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.)
EDUCATION & EXPERIENCE REQUIREMENTS
Bachelor's degree in a field related to health, psychology, sociology, social work, nursing or another relevant human services.
- Serving members or recipients with an I/DD or Traumatic Brain Injury (TBI)
- Two (2) years of experience working directly with individuals with I/DD or TBI
- Serving members with LTSS needs
- Two (2) years of prior Long-term Services and Supports and/or Home Community Based Services coordination, care delivery monitoring and care management experience.
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.
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 Careers.
Vaya Health is an equal opportunity employer.
