Care Manager (Caldwell County, NC)

LOCATION : Remote - must live in or near Caldwell 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, 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. 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. As further described below, essential job functions of the Care Manager include, but may not be limited to :

• 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

This position is required to meet NC Residency requirements as defined by the NC Department of Health and Human Services ("NCDHHS" or "Department"). This position is required to live in or near the counties served to effectively deliver in-person contacts with members and their care teams.

ESSENTIAL JOB FUNCTIONS

Assessment, Care Planning, and Interdisciplinary Care Team :

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.

Ensure the Care Plan includes specific services to address mental health, substance use, medical and social needs as well as personal goals

Provides crisis intervention, coordination, and care management if needed while with members in the community.

Collaboration, Coordination, Documentation :

Other duties as assigned.

KNOWLEDGE, SKILLS, & ABILITIES

BH I / DD Tailored Plan eligibility and services

EDUCATION & EXPERIENCE REQUIREMENTS

Bachelor's degree required, preferably in a field related to health, psychology, sociology, social work, nursing or another relevant human services area.

Two (2) years of experience working directly with individuals with BH conditions

Two (2) years of prior Long-term Services and Supports (LTSS) and / or Home Community Based Services (HCBS) coordination, care delivery monitoring and care management experience.

If graduate of a college or university with a Bachelor's degree in Human Services, then incumbent must have two years of full-time accumulated experience in mental health with population served.

If graduate of a college or university with a Bachelor's degree is in field other than Human Services, then incumbent must have four years of full-time accumulated experience in mental health with population served.

If a graduate of a college or university with a Bachelor's Degree in Nursing and licensed as RN, then incumbent must have four years of full-time accumulated experience in mental health with population served. Experience can be before or after obtaining RN licensure.

If graduate of a college or university with a Master's level degree in Human Services, although only one year of experience is needed to reach QP status, the incumbent must still have at least two years of full-time accumulated experience in mental health with the population served

Licensure / Certification Required :

Preferred work experience :

PHYSICAL REQUIREMENTS

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