Embedded Care Manager (Buncombe County)

This is a time limited position with an anticipated assignment period of 9-15 months.

LOCATION:  Remote – must live in or near Buncombe County, North Carolina.  This incumbent must reside in North Carolina or within 40 miles of the North Carolina border. This position serves Buncombe County DSS.

GENERAL STATEMENT OF JOB

The Embedded 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 Embedded Care Manager is a unique position within the Care Management Team who performs all standard Care Manager job functions, supports an assigned local DSS agency (through virtual or on-site embedding), provides consultation, education, focused communication, and system navigation for DSS social workers, and serves as the primary point of contact for supporting DSS emergency placement issues.

The Embedded Care Manager 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, with a focus on those members and families involved with DSS. Embedded Care Manager 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 Embedded 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 Embedded 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
• Consultation with DSS
• Education and System Navigation with DSS

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 and be onsite at local DSS offices.

ESSENTIAL JOB FUNCTIONS

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. 
• Administer the PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings within their scope based on member’s needs. The Embedded Care Manager 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 that other available clinical information is reviewed and incorporated into the assessment as necessary
  • Work with members to identify barriers and help resolve dissatisfaction with services or community-based interventions
• Reviews clinical assessments conducted by providers and partners with Embedded Care Manager - LP for clinical consultation as needed to ensure all areas of the member’s needs are addressed. Help 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 have the opportunity to 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 consults with clinical staff as needed to ensure all areas of the member’s needs are addressed
• 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 population health management programs.
• Works with the member/LRP and care team to ensure the development of a Care Management Crisis Plan for the members that is tailored to their needs and desires, which is separate and complementary to the behavioral health provider’s crisis plan.
  • Provides crisis intervention, coordination, and care management if needed while with members in the community.
• Supports Transitional Care Management responsibilities for members transitioning between levels of care
• Coordinates Diversion efforts for members at risk of requiring care in an institutional setting
• Consults with care management licensed professionals, care management supervisors, and other colleagues as needed to support effective and appropriate member care.

Collaboration, Coordination, Documentation:

• Coordinate and facilitate shared case staffing with DSS social workers, behavioral health providers, and Vaya care management in order to proactively plan for and communicate care needs.
  
• Provide clinical and administrative consultation for DSS social workers.
• Provide system navigation for DSS social workers to understand and work within the behavioral health system. Participate in DSS facilitated staffing to provide consultation and support.
• Serves as a collaborative partner in identifying system barriers through work with community stakeholders.  
• Works in partnership with other Vaya departments to identify and address gaps in services/ access to care within Vaya’s catchment.
• Participates in cross-functional clinical and non-clinical meetings and other projects as needed/ requested to support the department and organization.
• Participates in routine multidisciplinary huddles including RN, Pharmacist, M.D. to present complex clinical case presentation and needs, providing support to other CMs and receiving support and feedback regarding CM interventions for clients’ medical, behavioral health, intellectual /developmental disability, medication, and other needs.
• Works with Embedded Care Manager - LP in participating in other high risk multidisciplinary complex case staffing as needed to include Vaya CMO/ Deputy CMO, 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.
• Monitors provision of services to informally measure quality of care delivered by providers and identify potential non-compliance with standards.
• Ensures the health and safety of members receiving care management, recognize and report critical incidents, and escalate concerns about health and safety to care management leadership as needed.
• Supports problem-solving and goal-oriented partnership with member/LRP, providers, and other stakeholders.
• Promotes member satisfaction through ongoing communication and timely follow-up on any concerns/issues.
• Supports and assists members/families on services and resources by using educational opportunities to present information.
• Verifies member’s continuing eligibility for Medicaid, and proactively responds to a member’s planned movement outside Vaya’s catchment area to ensure changes in their Medicaid county of eligibility are addressed prior to any loss of service.
• Proactively and timely creates and monitors documentation within the AHR to ensure completeness, accuracy and follow through on care management tasks.
• Maintains electronic AHR compliance and quality according to Vaya policy.
• Works with Embedded Care Manager - LP to ensure all clinical and non-clinical documentation (e.g. goals, plans, progress notes, etc.) meet all applicable federal, state, and Vaya requirements, including requirements within Vaya’s contracts with NCDHHS.
• Participates in all required Vaya/ Care Management trainings, and maintains all required training proficiencies.

Other duties as assigned.

KNOWLEDGE, SKILL & ABILITIES

• Ability to express ideas clearly/concisely and communicate in a highly effective manner
• Ability to drive and sit for extended periods of time (including in rural areas)
• Effective interpersonal skills and ability to represent Vaya in a professional manner
• Ability to initiate and build relationships with people in an open, friendly, and accepting manner
• Attention to detail and satisfactory organizational skills
• Ability to make prompt independent decisions based upon relevant facts.
• Well-developed capabilities in problem solving, negotiation, arbitration and conflict resolution, including a high level of diplomacy and discretion to effectively negotiate and resolve issues with minimal assistance.
• A result and success-oriented mentality, conveying a sense of urgency and driving issues to closure
• Comfort with adapting and adjusting to multiple demands, shifting priorities, ambiguity, and rapid change
• Thorough knowledge of standard office practices, procedures, equipment, and techniques and intermediate to advanced proficiency in Microsoft office products (Word, Excel, Power Point, Outlook, Teams, etc.), and Vaya systems, to include the care management platform, data analysis, and secondary research
• Understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) within their scope and have considerable knowledge of the MH/SU/IDD/TBI service array provided through the network of Vaya providers. 
• Experience and knowledge of the NC Medicaid program, NC Medicaid Transformation, Tailored Plans, state-funded services, and accreditation requirements are preferred.
• Ability to complete and maintain all trainings and proficiencies required by Vaya, however delivered, including but not limited to the following:
  • BH I/DD Tailored Plan eligibility and services 
  • Whole-person health and unmet resource needs (ACEs, trauma-informed care, 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 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 
• 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.

QUALIFICATIONS & EDUCATION REQUIREMENTS

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

• Serving members with BH conditions:
  1. Two (2) years of experience working directly with individuals with BH conditions
• Serving members with LTSS needs
  1. 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.
  2. This experience may be concurrent with the two years of experience working directly with individuals with BH conditions, an I/DD, or a TBI, described above

--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

*Must meet the criteria of being a North Carolina Qualified Professional with the population served in 10A NCAC 27G .0104

Licensure/Certification Required:

Preferred work experience:

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 in 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. 

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.