Care Manager; Rowan County, NC

LOCATION

Remote - must live in or near Rowan County, North Carolina. The person in this position must maintain residency in North Carolina or within 40 miles of the North Carolina border. This position requires travel.

The Care Manager 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 works with the member and care team to 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 mental health, substance use, 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.

Care Managers 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 after‑care 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 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 Manager 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 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 (“NCDHHS” or “Department”). This position is required to live in or near the counties served to effectively deliver in‑person contacts with members and their care teams.

• 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 within their scope based on member’s needs. The Care Manager uses these screenings to provide specific education and self‑management strategies as well as linkage to appropriate therapeutic supports.
  • The assessment process includes reviewing and transcribing member’s current medication and entering information into Vaya’s Care Management platform, which triggers the creation of a multisource medication list that is shared back with prescribers to promote integrated care.
• 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 to address mental health, substance use, medical and social needs as well as personal goals
  • Ensure the Care Plan includes all elements required by NCDHHS
  • Use information collected in…