Care Manager - LP; Chatham County, NC

LOCATION:

Remote - must live in or near Chatham County, North Carolina. The person in this position is required to maintain residency in North Carolina or within 40 miles of the North Carolina 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 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 MH, SUD, I/DD, TBI, physical health, pharmacy, LTSS and unmet health-related resource needs.

Care Manager - LP supports and may provide clinical transition planning assistance to state and community hospitals and residential facilities and tracks individuals discharged from facility settings to ensure they follow up with aftercare services. 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 staff, members, relatives, caregivers/ natural supports, providers, and community stakeholders.

The Care Manager - LP utilizes licensed clinical knowledge and skills to assess needs, inform care planning development, provide clinical consultation, and offer recommendations for appropriate care.

As described below, essential job functions include, but are not 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 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 residency requirements as defined by the NC Department of Health and Human Services. The 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 formal/informal services and supports across health domains (medical and behavioral health)
• Meets with members to conduct the HRA and gather information on overall health, including behavioral health, developmental, medical, and social needs.
• Administers the PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings as needed. Uses these screenings to provide education and self-management strategies and linkage to therapeutic supports. The assessment includes reviewing and transcribing current medications and entering information into the Care Management platform to create a multisource medication list for prescribers.
• Supports the care team in development of a person-centered Care Plan that defines what is important for health and prioritizes goals for community living. The Care Plan includes services addressing mental health, substance use, medical and social needs, and personal goals; includes elements required by NCDHHS; uses assessment information to inform care planning; involves the care team as indicated; and helps resolve barriers to services.
• Provides information to member/LRP regarding service providers and ensures objectivity in the process. Works in an integrated care team with a RN and pharmacist to address needs and goals, and supports facilitation of care team meetings.
• Solicits input from the care team and monitors progress; ensures assessment, Care Plan, and other information is provided to the care team.
• Reviews assessments conducted by providers and consults with clinical staff as needed; provides clinical assessment in high-risk situations or time-sensitive placements/discharges.
• Updates Care Plans and Care Management assessments at least annually or when there is a significant life change; supports education and referral to prevention and population health programs; develops a tailored Care Management Crisis Plan in collaboration with the member/LRP and care team, separate from the behavioral health provider's crisis plan, including problem definition, health risks, and de-escalation techniques. Provides crisis intervention and care management as needed in the community.
• Supports…