Acute Transitional Care Manager

LOCATION:  Must live in or near Henderson County, NC. This position will be on-site at Pardee Hospital.  The person in this position is required to maintain residency in North Carolina or within 40 miles of the NC border.

GENERAL STATEMENT OF JOB

The Acute Transitional Care Manager (ATCM) is responsible for proactive intervention and coordination of care to members and recipients of Vaya's Health plan who are receiving care in an inpatient community hospital or Emergency Department in some instances who require complex care planning to alleviate inappropriate levels of care or care gaps through 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 within the Acute Transitional CM professional scope. The ATCM is responsible for knowing and implementing organizational policies, Division and departmental specific guidelines.

Activities may include but not limited to the following: 

• In cooperation with community hospital discharge planning teams, participate in developing transition plans, educating staff and members regarding network services and supports with consideration of medical necessity, funding eligibility and appropriateness of recommendations relative to person centered, recovery principles and known best/appropriate practice. 
• Develop, coordinate and link emergency discharge services (up to and including residential placement based on medical necessity, funding and service definitions or EPSDT for children/youth) for members who are inappropriately discharged from residential facilities (child or adult); coordination with Vaya's FastTrack process; notifying Vaya Health Network of provider contractual concerns or through established process if quality of care or health and safety concerns; 
• Notification and update of assigned community-based Care Manager (CM) and care team if member is currently assigned.
• Coordination and consultation with Vaya RN CM for transition management support.
• Transition to community-based CM post discharge.
• Participate in the development and implementation of best practice complex care strategies as identified by Vaya Health. 
• Provide proactive and clear supervision supported by data to ensure supervisors and teams are meeting departmental and organizational benchmarks; and 
• Collaborate with key stakeholders, network providers and non-network providers with particular attention to crisis, inpatient, 3-way bed contracts, NC START, etc.
• Engage and develop collaborative relationships with members using our Transitional Care Management and Tailored Care Management staff—such as our Care Managers and Peer Support Specialists—that use motivational interviewing techniques to understand the root causes that lead to exacerbation of symptoms and the use of emergency services or inpatient admissions 
• Address Unmet Health-Related Resource Needs that may be barriers to care or impacting the health of members
• Utilize ADT feeds and alerts to ensure prompt, efficient coordination and support

This position works with staff, community partners and members in Vaya Health catchment.

ESSENTIAL JOB FUNCTIONS

Acute Assessment, Care & Transition Planning & Interdisciplinary Care Team:

Conduct or ensure all elements of transitional care management are implemented for members during inpatient stay to include, but are not limited to the following:

• Proactively ensures that members assigned to Vaya CM have a CM assigned to manage the transition
• Links members, at a minimum, to primary care and behavioral health care.
• Ensures that the care plan includes a transition plan and ensure it is developed by care team or, if necessary, by the ATCM to meet needs and to access care for the individual.
• Convenes key providers and others to address needs of the individual, ideally in person or telephonically while member is still in facility.
• Visit the member during their stay in hospital and be, or be sure a member of the care team, is present on the day of discharge.
• Identifies gaps in services and supports, intervenes to ensure that the member receives and can access appropriate care.
• Measures results of intervention and treatment, including reduction a high-risk events and inappropriate service utilization.
• Ensures that services are coordinated across the Vaya Health system and with other systems, including primary care and Opportunities for Health services and supports.
• Provides clinical transition planning assistance to local community hospitals, and coordinates with care team, and tracks those discharged from local hospitals to ensure they follow up with aftercare services and receive needed assistance to prevent further hospitalizations.
• Assist the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence.
• Develop or begin development of a ninety (90) day post-discharge transition plan prior to discharge from inpatient settings, in consultation with the member, facility staff and the member's care team, that outlines how the member will maintain or access needed services and supports, transition to the new care setting, and integrate into their community.89/*kio8

Essential job functions of the ATCM include, but may not be limited to:  

• CM Platform basics
• Outreach & Engagement
• Release of Information practices
• Health Risk Assessment 
• Medication List and Continuity of Care process
• Care Planning
• Interdisciplinary Care Team and Ongoing Care Management

Collaboration:

This position will interface with key stakeholders and is responsible for understanding Vaya Health organizational goals, initiatives and requirements in order to effectively communicate and facilitate collaborative partnerships. This position is also expected to provide information from key stakeholder interactions to the appropriate departments and teams to improve the care continuum for members. Serve as a collaborative partner in identifying system barriers through work with community stakeholders, manages and facilitates care teams as appropriate.  

ATCM may participate in cross-functional clinical and non-clinical meetings and other projects to support the department and organization.  Participate in routine multidisciplinary huddles including RN, Pharmacist, M.D. to present complex clinical case presentation and needs, providing support to other CM's and receiving support and feedback regarding CM interventions for clients' medical, behavioral health, intellectual /developmental disability, medication, and other needs.  ATCM participates and ensures staff participate in other high risk multidisciplinary complex case staffing as needed to include Vaya Medical Director, 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.

Other duties as assigned.

KNOWLEDGE OF JOB

• Participate in and maintain Care Management and Vaya trainings and proficiencies as required. 
• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance.
• 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 co-workers and consumers/enrollees.
• Highly skilled between macro- and micro-level planning, maintaining a system and individual perspective. 
• Understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) 
• Knowledge of the MH/SU/IDD service array provided through the network of Vaya Health providers, Population Management, Disease Management and Risk Management principles and strategies.
• Knowledge in Vaya Health Medicaid B and C waivers, working knowledge state plan Medicaid and Medicare services, Vaya Health state funded initiatives and services, integrated care and accreditation is essential.
• Detail oriented, able to organize multiple tasks and priorities, and to effectively manage projects from start to finish.
• Work activities quickly change according to mandated changes and changing priorities within the department. The employee must be able to change the focus of his/her activities to meet changing priorities.
• 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.)

Training, learning and proficiency are tracked through the Care Management Training Matrix and any other required means.  Training may be delivered in a variety of methods and forums.  Understand the following areas, in addition to other required trainings: 

• BH I/DD Tailored Plan eligibility and services 
• Whole-person health and unmet resource needs (ACEs, Trauma, cultural humility) 
• Community integration (Independent living skills; transition and diversion, supportive housing, employment, etc.)
• Components of Health Home Care Management (Health Home overview, working in a multidisciplinary care team, etc.) 
• Health promotion (Common physical comorbidities, self-management, use of IT, care planning, ongoing coordination) 
• Other care management skills (Transitional care management, motivational interviewing, Person-centered needs assessment and care planning, etc.) 
• Serving members with I/DD or TBI (Understanding various I/DD and TBI diagnoses, HCBS, Accessing assistive technologies, etc.) 
• Serving children (Child- and family-centered teams, Understanding of the "System of Care" approach)
• Serving pregnant and postpartum women with SUD or with SUD history 
• Serving members with LTSS needs (Coordinating with supported employment resources

EDUCATION & EXPERIENCE REQUIREMENTS 

Bachelor's degree in a Human Services field such as social work, counseling, or psychology and 2 years of experience working with the identified population.

LICENSURE/CERTIFICATION REQUIREMENTS:  N/A

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; 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 REQUIREMENTS: The person in this position is required to reside in North Carolina or within 40 miles of the NC 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 

Vaya Health is an equal opportunity employer.