TCL Complex Care RN Evaluator; Hybrid, Charlotte, North Carolina

Position: TCL Complex Care RN Evaluator (Full-time Hybrid, Charlotte, North Carolina Based)
The TCL Complex Care RN Evaluator shall provide physical health and functional assessments and transition planning assistance primarily for TCL members transitioning from Adult Care Homes (ACHs), and to the extent capacity allows, to TCL members transitioning from other settings, with complex medical and/or functional conditions that significantly impede the transition of the member into the community (severity is determined by the PIHP screening process).

This position will require extensive travel and may include visits with members in Adult Care Homes and member living in the community. One day a week is required onsite at the Mecklenburg office in Charlotte, NC.

Responsibilities & Duties

Provide Care Team Support

• Support members transitioning from institutional care settings to community-based care
• Provide subject matter expertise, within scope of license, regarding member's physical health to support the development and delivery of a whole person approach to Care Management
• Work collaboratively with other Alliance staff, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities

Complete Assessments and Planning

• Utilize person-centered planning, motivational interviewing, and assessments to gather information
• Perform individual assessments/screenings for members that are medically fragile or have significant health conditions, have a mental health condition, substance use condition, or co-occurring intellectual or developmental disability
• In the Transition and Housing setting, staff will also assess and record member's activities and progress
• Provide education and supports to members and/or legal guardians regarding self-care strategies, their rights and responsibilities, available treatment options, provider network availability and payor requirements that may impact service access or maintenance
• Educate team members about impact of member's health conditions on service engagement, clinical outcomes, and prognosis for change
• Actively collaborate with member and care team members to ensure care plan accurately reflects the individual's clinical needs and desired life goals
• Update Assessments and plans of care as needed
• Provide education about advanced directives, preferred natural support and physical health contacts whom the member identifies, and preferred crisis facilities
• Provide medication reconciliation and education
• Develop and update plans of care based off the needs identified in the assessments and complete the interventions identified as needed
• Review member's medical history and identify specific goals and types of activities that will be used to help member work to help work towards those specific goals
• Proactively works with the member's multidisciplinary care team to identify gaps in services and intervenes to ensure that the member is receiving the appropriate level of care
• Assess members' homes to identify necessary modifications or durable medical equipment based on individual needs and provide instruction on the proper use of recommended equipment

Monitoring/Coordination

• Provide ongoing support for 90 days following the member's move, offering guidance and recommendations to help reduce crisis service or inpatient utilization and support long-term housing stability
• Appropriately escalate high risk/high visibility and/or complex barriers/needs members who may have difficulty transitioning out of the facility in a timely manner to supervisors. High risk can involve Health and Safety of a member, staff, or organizational risk
• Review cases with clinical complexity with direct supervisor, peer clinical review cohort, and utilization management care managers and medical management leadership as needed
• Obtain information releases that will improve care management activities on behalf of the member
• Reports care quality concerns to Quality Management as needed

Documentation

• Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency, and Medicaid requirements
• Follow administrative procedures and effectively manages caseload

Data

• Review, validate and interpret…