Care Manager - LP Franklin County

LOCATION:
Remote - must live in or near Franklin County, North Carolina.
The position must live in North Carolina or within 40 miles of the North Carolina border.
This position requires travel.

GENERAL STATEMENT OF JOB

The Care Manager Licensed Professional ("Care Manager - LP") 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 - LP works with the member and care team to identify and 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 Manager - LP supports and may provide clinical 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 - LP also works with other Vaya staff, members, relatives, caregivers/ natural supports, providers, and community stakeholders.
The Care Manager - LP also utilizes licensed clinical knowledge and skills to assess needs, inform care planning development, provide clinical consultation, and offer recommendations for appropriate care.

As further described below, essential job functions of the Care Manager - LP includes, 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 (Health Insurance Portability and Accountability) 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 (North Carolina) 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

Clinical Assessment, Care Planning, and Interdisciplinary Care Team:

• Ensures identification, assessment, and appropriate person-centered care planning for members.
  
  
• Links members with appropriate and necessary formal/ informal services and supports across all health domains (i.
  e.
  , medical, and behavioral health home)
• Meets with members to conduct the HRA and gather information on their overall health, including behavioral health, developmental, medical, and social needs.
  
• Administers the PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings based on member's needs.
  The Care Manager - LP uses these screenings to provide specific education and self-management strategies as well as linkage to appropriate therapeutic supports.
  
  • 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.
    
• Supports the care team in development of a person-centered care plan ("Care Plan") to help define what is important to members for their health and prioritize goals that help them live the life they want in the community of their choice.
  
  • Ensure the Care Plan includes specific services to address mental health, substance use, medical and social needs as well as personal goals
  • Ensure the Care Plan includes all elements required by NCDHHS
  • Use information collected in the assessment process to learn about member's needs and assist in care planning
  • Ensure members of the care team are involved in the assessment as indicated by the member/LRP and uses clinical skills to evaluate and incorporate other available clinical information into the assessment as necessary
  • Work with members to identify barriers and help resolve dissatisfaction with services or community-based interventions
• Uses clinical skills and expertise to review clinical assessments conducted by providers to ensure all areas of the member's needs are addressed.
  Care Manager - LP reviews for clinical accuracy and may provide consultation and technical support to providers as needed based on reviews.
  
• Interprets and analyzes clinical assessments to draw clinical conclusions to support care management activities.
  
• Engages with provider clinical staff to determine clinical appropriateness and course of action when assessments present a wide array of treatment options and members present with complex needs.
  
• Helps members refine and formulate treatment goals, identifying interventions, measurements, and barriers to the goals
• Ensures that member/legally responsible person ("LRP") is/are informed of available services, referral processes (e.
  g.
  , requirements for specific service), etc.
  

• Provides information to member/LRP regarding their choice of service providers, ensuring objectivity in the process
• Works in an integrated care team including, but not limited to, an RN and pharmacist along with the member to address needs and goals in the most effective way ensuring that member/LRP could decide who they want involved
• Supports and may facilitate care team meetings where member Care Plan is discussed and reviewed
• Solicits input from the care team and monitor progress
• Ensures that the assessment, Care Plan, and other relevant information is provided to the care team

• Reviews assessments conducted by providers and consult with clinical staff as needed to ensure all areas of the member's needs are addressed
• Provide clinical assessment in situations where the member's lack of clinical home or available network provider creates significant risk to member well-being (e.
  g.
  , need for time sensitive placement/ discharge from inpatient setting)
• Updates Care Plans and Care Management assessment at a minimum of annually or when there is a significant life change for the member
• Supports and assists with education and referral to prevention and pop.