Justice Reentry Coordinator - LP; Western North Carolina

LOCATION

Remote – must live in or near Vaya's Western North Carolina counties:
Buncombe, Henderson, Madison, Haywood, Jackson, Macon, Transylvania, Polk, McDowell, Avery, Yancey, or Mitchell. Incumbent must reside in North Carolina or within 40 miles of the NC border. This position requires travel in the community and visits to our members.

The primary purpose of this position is to serve individuals with serious mental illness (SMI) who are being released from a DAC (Department of Adult Corrections) Facility and will be prioritized for re‑entry coordination by both DAC and the applicable LME/MCO. The DAC Re‑Entry Coordinator ensures communication between all parties, including DAC and related divisions (health services, re‑entry, community supervision) and community behavioral and physical health providers.

Referrals are made to services including medication management, housing support, social determinants of health needs, behavioral and physical healthcare, and benefits coordination. Referrals will be made by DAC directly to the DAC Re‑Entry Coordinator approximately 90 days prior to release from incarceration.

This position allows Local Management Entities/Managed Care Organizations (LME/MCOs) to interact with individuals with severe mental illness who are within 90 days of releasing from a DAC Facility earlier on in the discharge planning process in an effort to better support positive outcomes upon their release. The coordinator will provide case management to individuals referred in the process, following them inductively until they qualify for tailored care management or another service such as Assertive Community Treatment.

The initial time period for this service is 90 days with the option to continue until needs are met.

The coordinator promotes an efficient, clinically sound, and person‑centered approach to supporting individuals through this process. Contact with community stakeholders is significant and the coord‑inator is responsible for ensuring a high level of quality in customer service, including strong collaborative relationships with providers and key stakeholders.

This is a mobile position with work done in a variety of locations. The coordinator spends a considerable amount of time in the field and completes required documentation at an office location or in the employee's home (as applicable).

• Possess knowledge of the needs of individuals with mental illness, and substance use/addiction disorders and effectively work with all individuals with respect on a level that they can understand and relate to
• Ensures all State mandated tasks related to dispositions and discharge are completed within benchmark time frames
• Ensures timely and thorough documentation of all efforts, both individual‑specific and programmatically, as requested by Supervisor
• Coordinates with key providers and others in a collaborative approach to address needs of the individual and ensure appropriate treatment planning and evaluation
• Promotes person‑centered practices, including use of person‑centered language and tools in planning
• Identifies gaps in services and intervenes to ensure that the individual receives appropriate care and discharge planning
• Focuses on achieving positive outcomes for individuals, regardless of disposition status, including reduction in high‑risk events and inappropriate service utilization
• Ensures that services for the individual are coordinated across the Vaya Health system and with other systems, including primary care. Refers to other specialists for timely assessment as clinically indicated
• Provides support and direction for the individual and his/her treatment team to ensure quality service and community integration
• Educates others about various housing options/resources and how to access them

• Partners with individuals/families, providers and community stakeholders, as applicable, to create solutions to issues/concerns, barriers to progress, etc.
• Works in partnership with other Vaya Health departments to address identified needs and opportunities to improve member outcomes
• Wor…