Care Manager - LP (Cherokee County, NC)

Care Manager Licensed Professional

Location: Remote must live in or near Cherokee County, North Carolina. The person in this position is required to maintain residency in North Carolina or within 40 miles of the NC border. This position requires travel.

The Care Manager Licensed Professional ("Care Manager - LP") 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 - LP works with the member and care team to identify and 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, I/DD, TBI physical health, pharmacy, long-term services and supports ("LTSS") and unmet health-related resource needs networks. Care Manager - LP supports and may provide clinical 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 - LP also works with other Vaya staff, members, relatives, caregivers/ natural supports, providers, and community stakeholders. The Care Manager - LP also utilizes licensed clinical knowledge and skills to assess needs, inform care planning development, provide clinical consultation, and offer recommendations for appropriate care.

Essential job functions of the Care Manager - LP includes, 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 (Health Insurance Portability and Accountability) 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 (North Carolina) 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.

Clinical 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.
• Administers the PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings based on member's needs. The Care Manager - LP 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.
• Uses clinical skills and expertise to review clinical assessments conducted by providers to ensure all areas of the member's needs are addressed. Care Manager - LP reviews for clinical accuracy and may provide consultation and technical support to providers as needed based on reviews.
• Interprets and analyzes clinical assessments to draw clinical conclusions to support care management activities.
• Engages with provider clinical staff to determine clinical appropriateness and course of action when assessments present a wide array of treatment options and members present with complex needs.
• Helps members refine and formulate treatment goals, identifying interventions, measurements, and barriers to the goals
• Ensures 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 process
• Works in an integrated care team including, but not limited to, an RN and pharmacist along with the member to address needs and goals in the most effective way ensuring that member/LRP could decide who they want involved
• Supports and may facilitate care team meetings where member Care Plan is discussed and reviewed
• Solicits input from the care team and monitor progress
• Ensures that the assessment, Care Plan, and other relevant information is provided to the care team
• Reviews assessments conducted by providers and consult with clinical staff as needed to ensure all areas of the member's needs are addressed
• Provide clinical assessment in situations where the member's lack of clinical home or available network provider creates significant risk to member well-being (e.g., need for time sensitive placement/ discharge from inpatient setting)
• Updates Care Plans and Care Management assessment at a minimum of annually or when there is a significant life change for the member
• Supports 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
• Ensures the crisis plan includes problem definition, physical/cognitive limitations, health risks/concerns, medication alerts, baseline functioning, signs/symptoms of crisis (triggers), de-escalation techniques.
• 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
• Consults with care management licensed professionals, care management supervisors, and other colleagues as needed to support effective and appropriate member care.

Collaboration, Coordination, Documentation:

• Utilizes advanced knowledge in their work which requires use of their advanced degree and licensure to be able to participate and initiate independent decisions with matters of significance and drive positive clinical outcomes for Vaya members.
• Executes independent discretion and engages in business decisions for the Vaya Care Management Department that support initiatives to promote Vaya's integrated, whole-person care model for members.
• 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.
• Participates 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.