Tribal Option Care Management Extender - LTSS

Job Description

Job Description

Primary Function

Care management extenders serve individuals who are eligible for Tailored Care Management, Intellectual Developmental Delays/Traumatic Brain Injury (I/DD/TBI), Long Term Service or Supports (LTSS) or those who are in the Children and Families Specialty Program (CSFP). Members require assistance to help them gain access to necessary care: medical, behavioral, social, community and other services appropriate to their needs. Services include person centered planning, referral and linkage, monitoring and follow-up. The duties of this position would include, but not limited to, representing care management when working with members, families, caregivers, as well as, other entities where a member may be seeking care, reside or receive services from.

Job Description

• Provide the following care management functions according to CIHA policy: assist with person centered planning; referral and linkage; and monitoring and follow-up.
• Ensuring that the care plan activities are carried out under the direction and/or delegation of the care manager or care manager supervisor.
• When assigned to provide services for adults, or for children and families, the employee will fulfill duties as outlined in EBCI TO policy and procedure for care management related to the specific population served.
• Gather and document necessary information in the EHR and/or the care management platform including medical, physical and functional, psychosocial, behavioral, financial, social, cultural, environmental, legal, and vocational or educational areas.
• Provides documentation of all significant events in Electronic Health Record and/or the care management platform, as prescribed by EBCI TO policies and procedures and quality assurance standards.
• Engage members in the person centered planning process, that is determined by the member’s care plan, to assist them in obtaining the outcomes, skills, and symptom reduction they desire.
• Link clients to needed services and supports.
• Provide timely information to care team members regarding member status, progress and safety. 
• Collaborate with the medical staff and other health professional/agencies to facilitate patient care, discharge and follow-up.
• Assist the care team in providing consultation to patient and family in matters directly related to patients' limitations, finances, adjustments to medical condition and ongoing treatment.
• Work with internal and external providers, and the member’s care team, to coordinate discharge planning, follow-up care, and transfers to other health facilities as appropriate.
• Responsible for attending staffing huddles, as an integral component of a care team, participating in the discussion of client data, and the formulation changes to the care plan/ISP.
• Participate in meetings to review and identify opportunities to improve care provided, and support the team in problem solving when concerns are identified.
• Participate in and assist with facilitating written, telephonic and face-to-face consultation services to various persons and organizations which affect the member. These include schools, courts, probation officers, physicians, hospitals, medical care providers, law enforcement officers, social services, community agencies, etc.
• Provide support to members in the office setting, as well as, the community setting by participating in the conducting of home visits with patients and staff, as needed.
• Collect and report on data necessary for member care according to procedure and as directed by supervisor.
• Arrange to visit the member in the new care setting after discharge/transition.
• Performs general outreach, engagement, and follow-up with members; 
• Provide coordination of services/appointments (e.g., appointment/wellness reminders, arranging transportation).
• Participate in health promotion activities (as defined in the Tailored Care Management Provider Manual) and knowledge sharing.  
• Shares information with the care manager and other members of the care team on the member’s circumstances, including gathering information about the member’s progress toward their goals. 
• Provides and tracks referrals and provides information and assistance in obtaining and maintaining community-based resources and social support services. 
• Participates in case conferences/Huddles.  
• Support the care manager in assessing and addressing unmet health-related resource needs .
• Facilitate arrangements for and scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven calendar days, unless required within a shorter time frame.
• Other duties as assigned.
• Support the TO Care Managers as needed.
• May be necessary to work when Administrative Leave is granted if patient care would be compromised.

Education/Experience/Minimum Qualifications

Care manager extenders must have the following qualifications: 

• At least 18 years of age; and 
• A high school diploma or equivalent (e.g., GED, certificate of completion); and 
• Employees who work with individuals who are Tailored Care Management eligible and/or IDD/TBI , must meet one of the following requirements: 

1. Be a person with lived experience with an I/DD or a TBI with demonstrated knowledge of and direct personal experience navigating the North Carolina Medicaid delivery system; or  
2. Be a person with lived experience with a behavioral health condition who is a Certified Peer Support Specialist; or 
3. A parent or guardian of an individual with an I/DD or a TBI or a behavioral health condition and has at least two years of direct experience providing care for and navigating the Medicaid delivery system on behalf of that individual (note that a parent/guardian cannot serve as an extender for their family member); or  
4. Has two years of paid experience performing the types of functions described in the essential duties and responsibilities section above, with at least one year of paid experience working directly with the Tailored Care Management eligible population. 

• Employees who work with individuals who are enrolled in CFSP, must meet one of the TCM and IDD/TBI requirements above or meet one of the following requirements: 

1. Certified Family Peer Specialist (Family Partners)
2. Certified Peer Support Specialist
3. Community health worker

• Must possess valid drivers' license.
• Specific experience working with Native Americans preferred.
• Current Basic Life Support (BLS) minimally required. Can be acquired through the facility within 6 months following appointment to position.

Job Knowledge

• Ability to learn computerized treatment systems such as EHR and the care management platform, and ability to maintain records and files manually and on the computer.
• Originality and initiative are required in the daily performance of tasks.
• Knowledge of principles, techniques, and practices, and their application to meet complex needs of the members.
• Knowledge of a wide range of medical, behavioral and psychosocial problems and linkage to treatment.
• Knowledge of governmental and private organizations and resources in the community.
• Knowledge impact of mental illness on patient’s ability to negotiate care recommendations, current care approaches, modalities of care, and substance abuse and other programs or services available to patients.
• Skill in establishing rapport with a patient and in applying techniques of engaging patients.
• Willingness learn more about Cherokee culture/population and to have considerations for this when identified.
• Ability to establish and maintain effective working relationships with patients and their families, other professional disciplines, and a variety of governmental and private resources and organizations in the community.
• Ability to express ideas clearly and concisely and to plan and work effectively in a team.

Complexity of Duties

This position is responsible for assisting in maximizing the available resources that best meets the constantly changing needs of the community. Must have the ability to interpret policy, laws and regulations in order to make decisions when a precedent is not available. Duties require the application of clinical judgment and problem solving skills in order to be effective.

Confidential Data

The provision of medical care requires that the incumbent maintain strict appropriate confidentiality regarding all patient information. The employee will have access to patient records and highly confidential information and must function with utmost integrity to safe guard this information. The employee complies with EBCI policy on confidentiality of patient records, Cherokee Indian Hospital Authority Confidentiality policy, HIPAA, 42CFR and other federal law requirements. Violations of confidentiality regulations may result in disciplinary action and other action as allowed by federal regulations.

Contacts with Others

Interacts frequently with coworkers, hospital staff, patients, stakeholders and other health professionals for the purpose of exchanging information, obtaining, or providing assistance. Serves on various local, community, and health committees, boards and advisory councils, as appropriate. Tact, courtesy, and professional conduct are required to maintain positive working relationships. Utmost sensitivity and confidentiality is required when dealing with patients and families.

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.

Mental/Visual/Physical   Expectations

Job duties can be mentally and emotionally stressful at times given the complexity of the duties, management and supervision of staff and the clinical areas being addressed with the people being served. Close mental concentration and attention to detail are required. Physical activities require the ability to be mobile, sit, reach, bend, and be in front of groups and deliver training for extended periods of time. Some physical exertion and stamina is required such as required to transport training materials or to travel. Must have visual acuity, manual dexterity, and the ability to speak and hear. Must be able to lift 30 lbs.

• Position requires: stand (under 1/3 time); walk (under 1/3 time); sit (to 2/3 time); talk or hear (over 2/3 time).
• Weight lifted or force exerted: none.
• Special vision requirements: Close vision (clear vision at 20 inches or less).

Resourcefulness and Initiative 

The supervisor provides specific detailed roles covering all assignments. The employee does not deviate from the roles unless authorized, but is encouraged to be resourceful and inventive when meeting the needs of the member. Incumbent works under the administrative supervision of the TO Specialty Team Care Manager Lead/TO Care Manager Supervisor, who controls the Department’s functional duties and provides specific instructions on assignments. Receives general instructions on assignments from the TO Specialty CM Lead. The incumbent is responsible for initiating and following through on recurring clerical assignments. Work is primarily reviewed in terms of overall quality and efficiency of service provided to members and staff by the TO Specialty CM Lead.

Responsibility for Accuracy

Most errors would be detected with proofing and review procedures. Failure to properly manage and direct activities could result in ill will for the department, delays in patient treatment, and negative patient and community relations. Ineffective health planning could have adverse effects on the health status of the community by limiting access to necessary resources. Accuracy of data and research is critical in the allocation of tribal resources. Responsible for the adherence to policy and procedure. Inappropriate actions or inaccuracies in judgment could result in improper diagnosis and treatment, serious liability for the tribe, or more serious health risks to members.

Supervision Received

Works under the direct guidance of the TO Care Manager Specialty lead/TO Care Manager Supervisor, where goals, objectives, policies, and procedures are well defined. Works independently within applicable licensing regulations where latitude for creative thinking, initiative and discretion are given to achieve department goals and objectives.

Work Environment

Must be flexible in working hours. This position offers a hybrid work model, with the flexibility to work remotely or from the designated work space. Specific workdays and location will be determined in collaboration with the team, the TO Care Manager Specialty Lead, and TO Care Manager Supervisor. The incumbent may occasionally be required to perform care management duties and tasks within the clinical setting.  Incumbent is required to comply with Employee Health Program guidelines including current immunization status of identified communicable diseases and safety precautions are sometimes necessary, such as use of personal protective equipment as required by hospital policy. The work environment involves moderate risks of exposure to infectious disease, radiation, electrical hazards, irritant chemicals and explosive gases. Some travel is required. Infrequent overnight travel may be required for meetings or to attend training.