LOCATION: Remote - must live in or near Jackson 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.
- Supports and may facilitate Care Team meetings where member Care Plan is discussed and reviewed.
- Participates in multidisciplinary huddles including RN, Pharmacist, M.D. and case staffings to present case to address barriers, identify need for specialized services to meet member needs and receive support and feedback regarding interventions for medical, behavioral health, I/DD, medication, and other needs.
- Risk Management- Proactively ensures that individuals identified as a Special Needs enrollee that have treatment needs or require regular monitoring have a Behavioral Health Clinical Home and a Medical Home.
- 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.
- 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.
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.
- 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.
- Ensure that services are monitored (including direct observation of service delivery) in all settings at required frequency and for compliance with standards.
- Proactively and timely creates and monitors documentation within the AHR to ensure completeness, accuracy and follow through on care management tasks.
- 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.
- Effective interpersonal skills and ability to represent Vaya in a professional manner.
- Attention to detail and satisfactory organizational skills.
- 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.
- 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.
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)
- Serving members with LTSS needs
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 https://www.vayahealth.com/about/careers/.
Vaya Health is an equal opportunity employer.
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