1915(i) Waiver Care Coordinator (Jackson/Macon/Haywood County)

1915(i) Waiver Care Coordinator

Location: Remote – must live in or near Jackson, Macon, or Haywood 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.

General Statement Of Job

The 1915(i) Waiver Care Coordinator ("Care Coordinator") 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. Care Coordinator is also responsible for providing care coordination activities and monitoring to individuals who have been deemed eligible for 1915i services by North Carolina Department of Health and Human Services (DHHS). Care Coordinator works with the member and care team to alleviate inappropriate levels of care or care gaps, coordinate multidisciplinary team care planning, linkage and/or coordination of services across the 1915i service array and other healthcare network(s) including 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. Care Coordinator 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 Care Coordinator also works with other Vaya staff, members, relatives, caregivers/natural supports, providers, and community stakeholders. As further described below, essential job functions of the Care Coordinator 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 NC Medicaid 1915i Assessment tool to gather information on the member's relevant diagnosis, activities of daily living, instrumental activities of daily living, social and work-related needs, cognitive and behavioral needs, and services the member is interested in receiving
• 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").

Essential Job Functions

Assessment, Care Planning and Interdisciplinary Care Team:

• Ensures identification, assessment, and appropriate person-centered care planning for members.
• Meets with members to complete a standardized NC Medicaid 1915i Assessment
• Links members with appropriate and necessary formal/informal services and supports across all health domains (i.e., medical, and behavioral health home)
• 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.
• Ensure the Care Plan includes specific services, including 1915(i) services to address mental health, substance use or I/DD, medical and social needs as well as personal goals
• Ensure the Care Plan includes all elements required by NCDHHS
• Use information collected in the assessment process to learn about member's needs and assist in care planning
• Ensure members of the care team are involved in the assessment as indicated by the member/LRP and that other available clinical information is reviewed and incorporated into the assessment as necessary
• Work with members to identify barriers and help resolve dissatisfaction with services or community-based interventions
• Reviews clinical assessments conducted by providers and partners with licensed staff for clinical consultation as needed to ensure all areas of the member's needs are addressed. Help 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 (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
• Solicits input from the care team and monitors progress
• Ensures that the assessment, Care Plan, and other relevant information is provided to the care team
• Consults with care management licensed professionals, care management supervisors, and other colleagues as needed to support effective and appropriate member care/planning process

Support Monitoring/Coordination, Documentation and Fiscal Accountability:

• Serves as a collaborative partner in identifying system barriers through work with community stakeholders.
• 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.
• Works with 1915 (i) Care Coordination manager in participating in 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.
• Ensure that services are monitored (including direct observation of service delivery) in all settings at required frequency and for compliance with standards
• 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.
• Make announced/unannounced monitoring visits, including nights/weekends as applicable.
• Promote satisfaction through ongoing communication and timely follow-up on any concerns/issues
• Monitor services to ensure that they are delivered as outlined in individualized service plan and address any deviations in service
• Verifies member's continuing eligibility for Medicaid, and proactively responds to a member's planned movement outside Vaya's catchment area to ensure changes in their Medicaid county of eligibility are addressed prior to any loss of service. Alerts supervisor and other appropriate Vaya staff if there is a change in member Medicaid eligibility/status.
• Maintain electronic health record compliance/quality according to Vaya policy
• Proactively monitor own documentation to ensure that issues/errors are resolved as quickly as possible
• Ensure accurate/timely submission of Service Authorization Requests (SARS) for all Vaya funded services/supports
• Proactively monitors own documentation within the AHR to ensure completeness, accuracy and follow through on care management tasks.
• Works with 1915 (i) Care Coordination Manager to ensure all clinical and non-clinical documentation (e.g., goals, plans, progress notes, etc.) meet all applicable federal, state, and Vaya requirements, including requirements within Vaya's contracts with NCDHHS.
• Participates in all required Vaya/ Care Management trainings and maintains all required training proficiencies.

Other duties as assigned.