Waiver Care Coordinator; Franklin​/Granville​/Vance

LOCATION: Remote - must live in or near Franklin, Granville, or Vance County, NC. Incumbent in this role is required to reside in North Carolina or within 40 miles of the North Carolina border. This position requires travel.

The 1915(i) Waiver Care Coordinator ("Care Coordinator") 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. Care Coordinator is also responsible for providing care coordination activities and monitoring to individuals who have been deemed eligible for 1915i services by North Carolina Department of Health and Human Services (DHHS).

Care Coordinator works with the member and care team to alleviate inappropriate levels of care or care gaps, coordinate multidisciplinary team care planning, linkage and/or coordination of services across the 1915i service array and other healthcare network(s) including 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.

Care Coordinator 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 Coordinator 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 Coordinator include, but may not be 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 NC Medicaid 1915i Assessment tool to gather information on the member's relevant diagnosis, activities of daily living, instrumental activities of daily living, social and work-related needs, cognitive and behavioral needs, and services the member is interested in receiving
• 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 ("NCDHHS" or "Department").

• Ensures identification, assessment, and appropriate person-centered care planning for members.
• Meets with members to complete a standardized NC Medicaid 1915i Assessment
• Links members with appropriate and necessary formal/ informal services and supports across all health domains (i.e., medical, and behavioral health home)
• 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, including 1915(i) services to address mental health, substance use or I/DD, medical and social needs as well as personal goals
  • Ensure the Care Plan includes all elements required by NCDHHS
  • Use information collected in the assessment process to learn about member's needs and assist in care planning
  • Ensure 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 necessary
  • Work with members to identify barriers and help resolve dissatisfaction with services or community-based interventions
• Reviews clinical assessments conducted by providers and partners with licensed staff 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 goals
• Ensures 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 process
• Works 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…