Care Manager

LOCATION: Remote - must live in or near Vaya‘s catchment area. This person must reside in North Carolina or within 40 miles of the NC border. Travel is required for this position.

GENERAL STATEMENT OF JOB

The Fast Track Care Manager (FT CM) is responsible for providing proactive and reactive intervention and coordination of care to eligible Care Management members identified as ‘At Risk‘ of not having a therapeutic residential setting to receive care. The focus is on youth in custody of the Department of Social Services (DSS). Executes the Fast Track Process which is a coordinated, expedited response to emergency placement needs identified by community partners. The FT CM is part of a small team whose primary function is to manage Fast Track situations across Vaya‘s catchment. This team works in conjunction with the primary CM.

The FT CM may carry a small caseload of members for care management for routine care management activities. This includes working with members and care teams to identify appropriate care, at the right time, place and duration through assessment, multidisciplinary team care planning, linkage and/or coordination of services across the MH/SU/IDD and other healthcare network(s) with existing or new care team members. Supports and may provide clinical transition planning assistance to local hospitals, tracks individuals discharged from state and community hospitals 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. The FT CM may work with members in their home communities. The FT CM also works with other Vaya staff, members and family members, providers as well as community stakeholders.

ESSENTIAL JOB FUNCTIONS

Fast Track Coordination:

• Provide full Fast Track support for youth involved with DSS or consultation support for any youth experiencing a potential placement disruption.
• Partners with the member, primary care manager, DSS, care team and other Vaya departments such as Utilization Management and Provider Network to quickly identify gaps and alleviate inappropriate levels of care.
• Partners with the team and identifies action items to work toward securing placement in the recommended level of care or a temporary placement while working toward the recommended placement.
• Utilize internal Vaya processes to pursue placement solutions, including the Request for Services and Specialty Needs Staffing processes.
• Schedule weekly team meetings with Member‘s care team while seeking placement and notifies involved parties upon placement resolution.
• Participate in state Rapid Response Team staffings as needed.

Mental Health/Substance Use (MHSU) Care Management:

• Meet with members to conduct a comprehensive bio-psycho-social assessment in order to gather information on their overall health, including behavioral health, developmental, medical, and social needs.
• Administer the PHQ-9, GAD, CRAFFT, ACES, LOCUS/ CALOCUS, and other assessments based on member‘s clinical needs and scores are calculated and reviewed allowing MHSU CM to provide specific education and self-management strategies as well as linkage to appropriate therapeutic support.
• Ensure members of the care team are involved in the assessment as indicated by the member and other available clinical information is reviewed and incorporated into the assessment as necessary.
• Review clinical assessments conducted by providers to ensure all areas of the member‘s needs are addressed.
• Assist members in refining and formulating treatment goals, identifying interventions, measurements, and barriers to the goals.
• Ensure Care Plans include specific services to address mental health, substance use or intellectual/ developmental disability, medical and social needs as well as personal goals.
• Partner with members and care teams to ensure care plans are developed at least once a year or anytime there is a significant life change.
• Ensure members/ guardians have the opportunity to decide who they want at the care team meeting and coordinates and may facilitate the team meeting where member Care Plan is discussed and reviewed.
• Certify the assessment, care plan and other relevant information is provided to the care team as indicated in Vaya policy.

KNOWLEDGE, SKILLS & ABILITIES

• Exhibit an extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) and have considerable knowledge of the MH/SU/DD service array provided through the network of Vaya providers. Knowledge in Vaya Medicaid B and C waivers and accreditation is essential.
• Knowledge of standard office practices, procedures, equipment, and techniques and have intermediate to advanced proficiency in Microsoft office products (Word, Excel, Power Point, Outlook, Teams, etc.)
• Detail oriented, able to organize multiple tasks and priorities, and to effectively manage projects.
• Ability to change the focus of his/her activities to meet changing priorities.
• Understand BH I/DD Tailored Plan eligibility and services
• Understand Whole-person health and unmet resource needs (ACEs, Trauma, cultural humility)
• Understand community integration (Independent living skills; transition and diversion, supportive housing, employment, etc.)
• Understand components of Health Home Care Management (Health Home overview, working in a multidisciplinary care team, etc.)
• Understand health promotion (Common physical comorbidities, self-management, use of IT, care planning, ongoing coordination)
• Care management skills (Transitional care management, motivational interviewing, Person-centered needs assessment and care planning, etc.)
• Ability to support members with I/DD or TBI (Understanding various I/DD and TBI diagnoses, HCBS, Accessing assistive technologies, etc.)
• Ability to support children (Child- and family-centered teams, Understanding of the ‘System of Care‘ approach)
• Ability to support pregnant and postpartum women with SUD or with SUD history
• Ability to support members with LTSS needs (Coordinating with supported employment resources
• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance.
• Exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts.
• Problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers.
• Highly skilled at shifting between macro and micro level planning, maintaining both the big picture, and seeing that the details are covered.
• Participate in and maintain Care Management and Vaya trainings and proficiencies as required.

QUALIFICATIONS & EDUCATION REQUIREMENTS

Bachelor‘s degree in a field related to health, psychology, sociology, social work, nursing or another relevant human services area or licensure as an RN* (see licensure section). Required experience:

• Serving members with BH conditions:
  • Two (2) years of experience working directly with individuals with BH conditions
• Serving members or recipients with an I/DD or Traumatic Brain Injury (TBI)
  • Two (2) years of experience working directly with individuals with I/DD or TBI
• Serving members with LTSS needs
  • Minimum requirements defined above
  • Two (2) years of prior Long-tern Services and Supports and/or Home Community Based Services coordination, care delivery monitoring and care management experience.
• This experience may be concurrent with the two years of experience working directly with individuals with BH conditions, an I/DD, or a TBI, described above

Licensure Required:

For those with a degree in nursing, incumbent must be a registered nurse who is licensed to practice in the State of North Carolina by the North Carolina Board of Nursing

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities that include viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.
  

RESIDENCY REQUIREMENT: The person in this is position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open until filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit about/careers/.

Vaya Health is an equal opportunity employer.