Care Manager - LP; Rockingham County, NC

LOCATION

Remote – must live in or near Rockingham 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, 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.

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

• 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

• 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.
• Interpret and analyze 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…