1915(i) Waiver Care Coordinator (Granville or Vance County, NC)

Overview LOCATION: Remote - must live in or near Granville or Vance County, NC. Incumbent in this role is required to reside in North Carolina or within 40 miles of the North Carolina border. This position requires travel. The 1915(i) Waiver Care Coordinator ("Care Coordinator") is responsible for providing proactive intervention and coordination of care to eligible Vaya Health members to ensure appropriate assessment and services. The Care Coordinator coordinates care across the 1915i service array and other health network components, including MH, SU, I/DD, TBI, medical, pharmacy, LTSS, and unmet health-related resource needs. This is a mobile role with work in members’ home communities and with a broad care team. Essential functions include: Utilization of Vaya’s Care Management software platform/AHR Outreach and engagement Compliance with HIPAA requirements, including ROI practices Performing NC Medicaid 1915i Assessment to gather member information (diagnoses, ADLs/IADLs, social and work-related needs, cognitive/behavioral needs, and services desired) Adherence to Medication List and Continuity of Care Participation in interdisciplinary care teams and care planning 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. Essential Job Functions Assessment, Care Planning and Interdisciplinary Care Team : Ensure identification, assessment, and person-centered care planning for members Meet with members to complete a standardized NC Medicaid 1915i Assessment Link members to appropriate formal/informal services across health domains Support the care team in developing a person-centered Care Plan with services, including 1915i services to address MH, SUD or I/DD, medical and social needs Ensure Care Plan includes elements required by NCDHHS Use assessment information to inform care planning and involve the care team as indicated Identify barriers and resolve dissatisfaction with services Review clinical assessments with licensed staff as needed to ensure needs are addressed Inform member/LRP of available services and referral processes Provide information to member/LRP regarding choice of service providers Work with RN and pharmacist as part of an integrated team to address needs Support and facilitate care team meetings and monitor progress Ensure assessment and Care Plan information is shared with the care team Consult with care management professionals to support planning Support Monitoring/Coordination, Documentation and Fiscal Accountability : Identify system barriers and work with community stakeholders Address gaps in services within Vaya’s catchment Participate in cross-functional meetings and projects Participate in routine multidisciplinary huddles to present complex cases Engage in high-risk multidisciplinary case staffing as needed Ensure services are monitored for compliance and quality Monitor and document quality of care Ensure health and safety of members and escalate concerns as needed Promote member satisfaction through ongoing communication and follow-up Assist members/families with services and resources Conduct announced/unannounced monitoring visits as applicable Monitor service delivery per individualized plan and address deviations Verify Medicaid eligibility and respond to changes in eligibility/status Maintain electronic health record compliance Monitor own documentation for completeness and accuracy Submit SARS for Vaya-funded services Ensure documentation meets federal, state, and contract requirements Participate in trainings and maintain proficiencies Other duties as assigned Knowledge, Skills & Abilities Clear and concise written and verbal communication Ability to drive and sit for extended periods (including rural areas) Professional interpersonal skills and representation of Vaya Ability to build relationships openly and respectfully Attention to detail and organization Decision-making using relevant facts Results-oriented with urgency to resolve issues Adaptability to multiple demands and change Proficient in MS Office and Vaya systems, including care management platform and data analysis Understanding of DSM (current version) within MH/SU/IDD/TBI services Experience/knowledge of NC Medicaid program, transformation, Tailored Plans, and accreditation Ability to complete required trainings and proficiencies, including but not limited to listed topics Education & Experience Requirements Bachelor’s degree in a health, psychology, sociology, social work, nursing or related field is preferred. Experience: Two (2) years of experience working directly with individuals with BH conditions Two (2) years of experience with individuals with I/DD or TBI Two (2) years of experience with LTSS coordination or related care management Alternatively, a combination of education and experience as specified (see original text for details) OR a combination of education and experience as follows: A Bachelor's degree in a human services field and two years of full-time experience with the population served; or a Bachelor's degree in a non-human services field and four years of full-time experience; or a Bachelor's in Nursing with RN licensure and four years of experience; or Master's degree in Human Services with at least two years of experience with the population served. Licensure/Certification Required: If Bachelor’s in Nursing, incumbent must be licensed as an RN in NC. Physical Requirements Close visual acuity for documents and computer work Physical activity includes crouching, reaching, walking, talking, hearing, and repetitive hand motions Sedentary work with lifting up to 10 pounds, extended sitting Mental concentration required Ability to drive and sit for extended periods Residency Requirement: Must reside in North Carolina or within 40 miles of the NC border. Salary: Depending on qualifications and experience. Non-exempt and eligible for overtime. Deadline for Application: Open Until Filled Apply: Vaya Health online via Career Center at Vaya Health is an equal opportunity employer. #J-18808-Ljbffr Vaya Health