Care Manager (Alamance County, NC)
Company: Vaya Health
Location: Burlington
Posted on: January 25, 2025
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Job Description:
LOCATION: Remote - must live in or near Alamance County, North
Carolina. The position must live in North Carolina or within 40
miles of the North Carolina border. This position requires travel.
GENERAL STATEMENT OF JOBThe Care Manager 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 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. Care Managers
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 Manager 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 Manager include, but may not be limited to:Utilization
of and proficiency with Vaya's Care Management software platform/
administrative health record ("AHR")Outreach and
engagementCompliance with HIPAA requirements, including
Authorization for Release of Information ("ROI")
practicesPerforming 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 careAdherence to
Medication List and Continuity of Care processesParticipation in
interdisciplinary care team meetings, comprehensive care planning,
and ongoing care managementTransitional Care ManagementDiversion
from institutional placementThis 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 FUNCTIONSAssessment, 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 Care Manager uses these
screenings to provide specific education and self-management
strategies as well as linkage to appropriate therapeutic supports.
The assessment process includes reviewing and transcribing member's
current medication and entering information into Vaya's Care
Management platform, which triggers the creation of a multisource
medication list that is shared back with prescribers to promote
integrated care.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 to address
mental health, substance use, medical and social needs as well as
personal goalsEnsure the Care Plan includes all elements required
by NCDHHSUse information collected in the assessment process to
learn about member's needs and assist in care planningEnsure
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
necessaryWork with members to identify barriers and help resolve
dissatisfaction with services or community-based
interventionsReviews clinical assessments conducted by providers
and partners with Care Manager - LP and Care Manager Embedded - LP
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 goalsEnsures 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 processWorks 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 reviewedSolicits
input from the care team and monitor progressEnsures that the
assessment, Care Plan, and other relevant information is provided
to the care team Reviews assessments conducted by providers and
consults with clinical staff as needed to ensure all areas of the
member's needs are addressedUpdates Care Plans and Care Management
assessment at a minimum of annually or when there is a significant
life change for the memberSupports 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.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 careCoordinates Diversion efforts
for members at risk of requiring care in an institutional
settingConsults with care management licensed professionals, care
management supervisors, and other colleagues as needed to support
effective and appropriate member care. Collaboration, Coordination,
Documentation: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.Works with
Care Manager - LP and Care Manager Embedded - LP in participating
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.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.Proactively and timely creates and monitors
documentation within the AHR to ensure completeness, accuracy and
follow through on care management tasks.Maintains electronic AHR
compliance and quality according to Vaya policy.Works with Care
Manager - LP and Care Manager Embedded - LP 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. KNOWLEDGE, SKILL & ABILITIESAbility to express ideas
clearly/concisely and communicate in a highly effective
mannerAbility to drive and sit for extended periods of time
(including in rural areas)Effective interpersonal skills and
ability to represent Vaya in a professional mannerAbility to
initiate and build relationships with people in an open, friendly,
and accepting mannerAttention to detail and satisfactory
organizational skillsAbility to make prompt independent decisions
based upon relevant facts.Well-developed capabilities in problem
solving, negotiation, arbitration, and conflict resolution,
including a high level of diplomacy and discretion to effectively
negotiate and resolve issues with minimal assistance.A result and
success-oriented mentality, conveying a sense of urgency and
driving issues to closureComfort with adapting and adjusting to
multiple demands, shifting priorities, ambiguity, and rapid
changeThorough 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, to include the care management
platform, data analysis, and secondary researchUnderstanding 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. Experience and knowledge of the NC Medicaid program, NC
Medicaid Transformation, Tailored Plans, state-funded services, and
accreditation requirements are preferred.Ability to complete and
maintain all trainings and proficiencies required by Vaya, however
delivered, including but not limited to the following:BH I/DD
Tailored Plan eligibility and services Whole-person health and
unmet resource needs (ACEs, trauma-informed care, cultural
humility) Community integration (independent living skills;
transition and diversion, supportive housing, employment,
etc.)Components of Health Home Care Management (Health Home
overview, working in a multidisciplinary care team, etc.) Health
promotion (common physical comorbidities, self-management, use of
IT, care planning, ongoing coordination) Other care management
skills (transitional care management, motivational interviewing,
person-centered needs assessment and care planning, etc.) Serving
members with I/DD or TBI (understanding various I/DD and TBI
diagnoses, HCBS, Accessing assistive technologies, etc.) Serving
children (child-and family-centered teams, Understanding the
"System of Care" approach)Serving pregnant and postpartum women
with SUD or with SUD history Serving members with LTSS needs
(Coordinating with supported employment resources Job functions
with higher consequences of error may be identified, and
proficiency demonstrated and measured through job simulation
exercises administered by the supervisor where a minimum threshold
is required of the position. QUALIFICATIONS & EDUCATION
REQUIREMENTSBachelor's degree required, preferably in a field
related to health, psychology, sociology, social work, nursing or
another relevant human services area.
RESIDENCY REQUIREMENT: The person in 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 . Vaya Health is an equal opportunity
employer.
Keywords: Vaya Health, Durham , Care Manager (Alamance County, NC), Executive , Burlington, North Carolina
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