Care Coordinator

LOCATION : Remote must live in NC or within 40 miles of the NC border

GENERAL STATEMENT OF JOB

The Member and Recipient Services Care Coordinator (MRSCC) is responsible for providing proactive intervention and telephonic coordination of care to members that have opted out of Tailored Plan Care Management (TCM) to ensure that these individuals receive appropriate assessment, services, and care transitions, for members that opt-out or have never engaged in TCM to prevent unplanned or unnecessary readmissions, ED visits, and adverse outcomes.

This excludes members eligible for Innovations, Innovation members, TBI, or LTSS who will receive Care Coordination through Vaya’s Care Management team.

Note : This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws.

As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his / her capacity as an employee of Vaya Health.

The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

ESSENTIAL JOB FUNCTIONS

Outreach and Engagement :

MRSCC shall perform the following care coordination functions for members who are not participating in Tailored Care Management.

MRSCC’s will provide outreach and engagement through telephonic coordination to members who have opted out of Tailored Plan Care Management.

This will include Standardized unmet health-related Member Recipient Services Care Coordination in all care needs screenings, covering the 4 Priority domains : housing, food, transportation, and interpersonal violence / toxic stress.

MRSCC’s ensures identification, assessment, and appropriate Person-Centered Care Planning for members identified as having Special Health Care Needs or as High-Risk High-Cost members to determine and link to appropriate formal and informal services, supports, and community resources including a medical and behavioral health home and monitor services.

This excludes members with Innovations, eligible for Innovations services, TBI, or LTSS. MRSCC’s conduct assessments to gather information on member’s overall health, including behavioral health, developmental, medical, and social needs.

The MRSCC assessment addresses social determinants of health, mental health history and needs, physical health history and needs, intellectual / developmental disabilities, activities of daily living, access to resources, and other areas to ensure a whole person approach to care.

The assessment process includes reviewing and transcribing member’s current medication and entering information into the Care Needs Screening.

MRSCC’s ensure that each enrollee has an ongoing source of care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the services accessed by the member.

The member must be provided information on how to contact their designated person or entity.

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

• Outreach & Engagement
• Release of Information practices
• Member Services Care Coordination Assessment
• Medication List
• Care Planning

Assessments are completed at least annually, and anytime there is a significant life change or as indicated in Vaya policy.

Care Planning :

MRSCC use the Care Needs Screening to create a person-centered care plan for members to help define what is important to members for their health.

Person-Centered Care Plans are created based on information collected in the care needs assessment process. MRSCC will assist members in refining and formulating treatment goals, identifying interventions, measurements, and barriers to the goals and monitor progress.

MRSCC 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.

MRSCC work with members and care teams to ensure care plans are developed at least once a year or anytime there is a significant life change.

Other elements of Care Needs Planning include :

• 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.
• Ensures that a Person-Centered Plan (PCP) is developed by a Behavioral Health Clinical Home or, if necessary, by the Care Coordinator to meet urgent needs and to access care for the individual.
• Executes skills in Motivational Interviewing (MI), as well as Screening, Brief Intervention, and Referral to Treatment.
• Identifies gaps in services and intervenes to ensure that the individual receives appropriate care.
• Measures results of intervention and treatment, including reduction in high-risk events and inappropriate service utilization.
• Ensures that services for the individual are coordinated across the Vaya system and with other systems, including primary care.
• Crisis planning with member. MRSCC will create a care coordination plan which is a separate but complimentary to the behavioral health provider’s crisis plan.

MRSCC collaborates with members to develop a Crisis Plan that is tailored to their needs and desires. The MRSCC ensures the crisis plan includes problem definition, physical / cognitive limitations, health risks / concerns, medication alerts, baseline functioning, signs / symptoms of crisis (triggers), de-escalation techniques.

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

Other duties as assigned.

KNOWLEDGE, SKILL & ABILITIES :

Employee will participate in and maintain MRSCC 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.

This will require 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.

Must be highly skilled at shifting between macro and micro level planning, maintaining both the big picture, and seeing that the details are covered.

The employee must be 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.

• 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.)
• Health promotion (Common physical comorbidities, self-management, use of IT, care planning, ongoing coordination)
• Person-centered needs assessment and care planning, etc.)
• Serving pregnant and postpartum women with SUD or with SUD history

MRSCC’s should be proficient in the essential job functions. Job functions with higher consequences of error may be identified, and proficiency demonstrated and measured through job simulation exercises administered by the supervisor where a minimum threshold is required of the position.

In addition, MRSCC’s must have thorough 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.).

QUALIFICATIONS & EDUCATION REQUIREMENTS

Bachelor’s degree in a Human Service-related field (such as Psychology, Social Work, etc.) and two (2) years of post-degree progressive experience providing similar services to the population served.

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.
• Ability to drive and sit for extended periods of time (including rural areas).

RESIDENCY REQUIREMENT :

This 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 non-exempt and is eligible for overtime compensation.