Innovations Care Manager (Southeastern NC)

LOCATION: Remote – must live in or near the following counties in Southeastern North Carolina: Columbus, Robeson, Hoke, Cumberland, or Brunswick. Incumbent in this role must live in North Carolina or within 40 miles of the NC border. This position requires travel. GENERAL STATEMENT OF JOB Innovations Care Manager (Innovations CM) 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 Innovations CM 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, 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. Innovations CMs 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 Innovations CM also works with other Vaya staff, members, relatives, caregivers/ natural supports, providers, and community stakeholders.

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 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. Administer the PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings within their scope based on member’s needs. The Innovations CM 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 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 Innovations CM, LP and Manager, IDD Care Management, LP or Director, Care Management 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, etc. (i.e. Individual/Family Direction for Innovations participants), processes (e.g., requirements for specific service), etc. Provide information to member/LRP regarding their choice in choosing 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 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. Update 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. Participate in multidisciplinary huddles including RN, Pharmacist, M.D. and case staffings to present case to address barriers, identify need for specialized services to meet member needs and receive support and feedback regarding interventions for medical, behavioral health, I/DD, medication, and other needs and provide support to other Care Managers. Risk Management- Proactively ensures that individuals identified as a Special Needs enrollee that have treatment needs or require regular monitoring have a Behavioral Health Clinical Home and a Medical Home. 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 provider’s crisis plan. Provides crisis intervention, coordination, and care management if needed while with members in the community. Supports Transitional Care Management responsibilities for members transitioning between levels of care. Coordinates Diversion efforts for members at risk of requiring care in an institutional setting. Consults with care management licensed professionals, care management supervisors, and other colleagues as needed to support effective and appropriate member care. Support Monitoring/Coordination, Documentation and Fiscal Accountability: Serves as a collaborative partner in identifying system barriers through work with community stakeholders. Manages and facilitates Child/Adult High-Risk Team meetings in collaboration with providers, stakeholders and other community supports as appropriate. Participates in cross-functional clinical and non-clinical meetings and other projects as needed/ requested to support the department and organization. Participates in routine multidisciplinary huddles including RN, Pharmacist, M.D. to present complex clinical case presentation and needs, providing support to other CMs (Care Manager) and receiving support and feedback regarding CM interventions for clients’ medical, behavioral health, intellectual /developmental disability, medication, and other needs. Works in partnership with other Vaya departments to identify and address gaps in services/ access to care within Vaya’s catchment. Works with Innovations CM, LP and IDD Manager- LP in participating in other high risk multidisciplinary complex case staffing as needed to include Vaya CMO/ Deputy CMO, Utilization Management, Provider Network, and Care Management leadership to address barriers, identify need for specialized services to meet client needs within or outside the current behavioral health system. Ensures the health and safety of members receiving care management, recognize and report critical incidents, and escalate concerns about health and safety to care management leadership as needed. Ensure that services are monitored (including direct observation of service delivery) in all settings at required frequency and for compliance with standards. Make announced/unannounced monitoring visits, including nights/weekends as applicable. Monitors provision of services to informally measure quality of care delivered by providers and identify potential non-compliance with standards. Supports problem-solving and goal-oriented partnership with member/LRP, providers, and other stakeholders Promotes member satisfaction through ongoing communication and timely follow-up on any concerns/issues. Supports and assists members/families on services and resources by using educational opportunities to present information. Educate members/families on methodology for budget development, total dollar value of the budget and mechanisms available to modify the individual budget. Monitor services to ensure that they are delivered as outlined in individualized service plan and address any deviations in service. Ensure that service orders/doctor’s orders are obtained, as applicable. Verifies member’s continuing eligibility for Medicaid, and proactively responds to a member’s planned movement outside Vaya’s catchment area to ensure changes in their Medicaid County of eligibility are addressed prior to any loss of service. Alerts supervisor and other appropriate Vaya staff if there is a change in member Medicaid eligibility/status. Proactively and timely creates and monitors documentation within the AHR to ensure completeness, accuracy and follow through on care management tasks. Coordinate Medicaid deductibles, as applicable, with the individual/guardian and provider(s). Proactively monitor own documentation to ensure that issues/errors are resolved as quickly as possible. Ensure accurate/timely submission of Service Authorization Requests (SARS) for all Vaya funded services/supports. Works with Innovations CM, LP and Manager, Innovations Care Management, LP to ensure all clinical and non-clinical documentation (e.g. goals, plans, progress notes, etc.) meet all applicable federal, state, and Vaya requirements, including requirements within Vaya’s contracts with NCDHHS. Alert supervisor and other appropriate Vaya staff if there is a change in member Medicaid eligibility/status. Participates in all required Vaya/ Care Management trainings and maintains all required training proficiencies. Other duties as assigned.