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Integrated Care Coordinator

2 months ago


Columbia, South Carolina, United States Vaya Health Full time

LOCATION: Remote – must reside in or near Alamance County, North Carolina. This role is designated for individuals living in North Carolina or within 40 miles of the state border.

GENERAL OVERVIEW:

The Integrated Care Coordinator plays a vital role in delivering proactive support and care coordination for eligible members of Vaya Health. This position is distinct within the Care Management Team, focusing on the collaboration with a designated local Department of Social Services (DSS) agency. The Coordinator provides consultation, education, and effective communication to DSS social workers, serving as the primary resource for addressing emergency placement challenges.

The Integrated Care Coordinator collaborates with members and their care teams to identify and mitigate inappropriate care levels or service gaps. This involves comprehensive assessments, multidisciplinary care planning, and linking members to necessary services across various health domains, including mental health, substance use, intellectual/developmental disabilities, and physical health. The role also encompasses transition planning assistance for individuals moving from state and community hospitals, ensuring follow-up with aftercare services to prevent readmission.

KEY RESPONSIBILITIES:

  • Utilization of Vaya's Care Management software for effective documentation and tracking.
  • Engagement and outreach to members and stakeholders.
  • Adherence to HIPAA regulations and confidentiality practices.
  • Conducting comprehensive Health Risk Assessments (HRA) to evaluate members' overall health and social needs.
  • Participation in interdisciplinary care team meetings and ongoing care management processes.
  • Facilitating transitional care management and diversion strategies for members at risk of institutional placement.
  • Providing educational resources and system navigation support to DSS social workers.

This position requires compliance with North Carolina residency requirements as outlined by the North Carolina Department of Health and Human Services. The Integrated Care Coordinator must be present in the communities served to ensure effective in-person interactions with members and their care teams.

QUALIFICATIONS:

A Bachelor's degree in a relevant field such as health, psychology, sociology, or social work is required. Candidates should possess experience working directly with individuals facing behavioral health challenges and have a strong understanding of the North Carolina Medicaid program and its services.

PHYSICAL DEMANDS:

  • Ability to perform activities requiring close visual acuity and extensive reading.
  • Physical activity may include walking, talking, and repetitive motions.
  • Must be able to drive and sit for extended periods.

SALARY: Compensation will be based on the qualifications and experience of the candidate. This position is classified as non-exempt and is eligible for overtime pay.