Care Manager; Jackson County, NC

Overview

LOCATION: Remote - must live in or near Jackson 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.

GENERAL STATEMENT OF JOB

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 MH, SU, I/DD, TBI, physical health, pharmacy, 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 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 also works with other Vaya staff, members, relatives, caregivers/ natural supports, providers, and community stakeholders.

Essential job functions include the items listed below.

Assessment, Care Planning, and Interdisciplinary Care Team

• 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. This includes:
• 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 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 Care Manager - LP and Care Manager Embedded - LP 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/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 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 discussed and reviewed
• Solicits input from the care team and monitor progress
• Ensures that the assessment, Care Plan, and other relevant information is provided to the care team
• Reviews assessments conducted by providers and consults with clinical staff as needed to ensure all areas of the member s needs are addressed
• Updates Care Plans and Care Management assessment at a minimum of annually or when there is a significant life change for the member
• Supports and assists with education and referral to prevention and population health management programs.
• Works with the member/LRP and care team to ensure the development of a Care Management Crisis Plan for the member that is tailored to their needs and desires, which is separate and complementary to the behavioral health…