Acute Transition Care Management RN (Caldwell County)

LOCATION:  Remote – must live in or near Caldwell County, North Carolina. Must have the ability to travel in or near Vaya’s region.

GENERAL STATEMENT OF JOB

Acute Transition Care Manager, Registered Nurse (ATCM, RN) reports to the Acute Transition Care Management, Registered Nurse Manager (ATCM, RN Manager) and is responsible for providing proactive intervention and coordination of care to Vaya Health members and recipients (“members”) who are receiving care in an inpatient community hospital or emergency department for physical health reasons to ensure that these individuals receive appropriate transitional care and services. ATCM, RN 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, while ensuring existing or new care team members are informed of transition plan. This position supports and may provide clinical transition planning assistance to community hospitals and tracks individuals discharged from facility settings to ensure they follow up with aftercare services and receive needed assistance to prevent further hospitalization.  The ATCM RN promotes effective cross-organization communication and maintains collaborative relationships within the organization to achieve division objectives.  The ATCM, RN maintains skills in care management, care coordination, disease management and patient transitional care management. This position may work with internal staff, hospital staff, members, guardians/family members, community stakeholders and others as appropriate to meet member’s transitional needs.  Performs other duties as assigned.  The ATCM, RN also utilizes licensed clinical knowledge and skills to assess needs, inform transition planning development, provide clinical consultation, and offer recommendations for appropriate care.

As further described below, essential job functions of the ATCM, RN 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”). 

*In some circumstances, to best meet member, provider and stakeholder needs, this position working hours to begin before Vaya's 8:30am hours of operation

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 physical health inpatient stay to include, but are not limited to the following: 

• Proactively identify Vaya members and ensure assignment to TCM or CC to manage the transition; 
• Meets with members to conduct transitional care management and gather information on their overall health, including behavioral health, developmental, medical, and social needs;
• Provide transition planning for members not already engaged in Tailored Care Management;
• Use clinical skills and expertise to review clinical assessments and transition plans conducted by providers to ensure all areas of the member’s transitional care needs are addressed;
• Work in an integrated care team including, but not limited to, doctors 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;
• Link members to appropriate follow-up services including physical health, pharmacy, behavioral health and other identified social determinate of health needs;
• Ensure that the care plan includes a transition plan developed by care team or, if necessary, by the ATCM, RN to meet needs and to access care for the individual;
• Convene key providers and others to address needs of the individual including participation in in-person or telephonic treatment team meetings, while the member is still in the facility;
• Support and assists with education and referral to prevention and population health management programs
• Coordinate Diversion efforts for members at risk of requiring care in an institutional setting
• Visit, or make best effort to contact, 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 when possible;
• Identify gaps in services and supports, intervenes to ensure that the member receives and can access appropriate care;
• Measure results of intervention and treatment, including reduction a high-risk events and inappropriate service utilization;
• Ensure that services are coordinated across the Vaya Health system and with other systems, including primary care, Opportunities for Health services and supports, social determinants of health, nursing facilities and/or specialist;
• Ensure development of a written discharge plan through a person-centered planning process in which the member has a primary role and which is based on the principle of self-determination.        Include the discharge plan in the member’s care plan;
• Provide clinical transition planning assistance to local community hospitals, and coordinates with care team, and tracks those discharged from local hospitals to ensure timely follow up with aftercare services to prevent further hospitalizations;
• Assist the member in obtaining needed medication/prescriptions 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 physical health 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;
• Ensure that any barriers preventing the member from being discharged and transitioning into the chosen integrated setting are recorded in the member’s Care Plan and actively seek solutions for addressing those barriers;
• Ensures all required documentation is completed and submitted by inpatient facility for member’s transitioning to a Skilled Nursing Facility (SNF) due to complexity of cases, for ensures timely transition to SNF;
• Comply with Continuity of Care and Tailored Care Management continuum and Vaya policies and procedures while ensuring person-centered principles are utilized in transitional care planning activities;
• Consult with care managers, care management supervisors, ATCM RN Manager, medical team leaders, and other colleagues as needed to support effective and appropriate member care.
• Address barriers to care for members through convening key providers and others to address needs of the individual and escalate for clinical consultation when necessary;
• Identify and communicate gaps in care related to services and intervenes to ensure that the individuals and specialty populations receive appropriate care;
• Notify and update assigned providers and provide support if provider does not engage or follow up appropriately. 
• In cooperation with Hospital Emergency Department or Inpatient physical health 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 plan, recovery principles and known best/appropriate practice;
• Conduct clinical hand-off to community-based CC or CM post discharge;
• Document contacts, completed activities, assessments and other relevant information within the administrative health record;
• Participate in the development and implementation of best practice complex care strategies as identified by Vaya Health; 
• Utilize data feeds and alerts to ensure prompt, efficient coordination and support.

Collaboration, Coordination, Documentation: 

• Executes independent discretion and engages in business decisions for the Vaya Care Management Department that support initiatives to promote Vaya’s integrated, whole-person care model for members.
• 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.
• Collaborates with Population Health Division teams regarding routine care planning, discharge planning, transitional care plans, education of 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.
• Participates 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.
• 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.
• Interface with key stakeholders in physical health inpatient units and is responsible for understanding Vaya organizational goals, initiatives, and requirements to effectively communicate and facilitate collaborative partnerships and collaboration with key stakeholders, providers and healthcare systems;
• Participates in all required Vaya/ Care Management trainings and maintains all required training proficiencies.
• 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.
• Ensures 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 Vaya committees, workgroups, and other efforts that require clinical knowledge, as requested, and identified.

Performs other related tasks as required:

• Attend agency staff/department meetings as appropriate;
• Receive continuing education training as necessary to maintain licensure and other training requirements; and,
• Other duties as required for role. 

KNOWLEDGE, SKILL & ABILITIES

• Capacity to provide clinical leadership and direct oversight of ATCM, RN staff and ensures achievement of individual and team performance and productivity standards
• Ability to implement process improvement interventions and develops staff in an environment that is motivating
• Ability to express ideas clearly/concisely and communicate in a highly effective manner
• Exceptional interpersonal skills and ability to represent Vaya in a professional manner
• An ability to initiate and build relationships with people in an open, friendly, and accepting manner
• Ability to take ownership of projects from planning through execution
• Strong attention to detail and superior organizational skills
• Ability to multitask and prioritize to manage multiple projects on tight timelines
• Ability to understand the strategic direction and goals of the department and support appropriate processes to facilitate achievement of business objectives
• Well-developed capabilities in problem solving, negotiation, conflict resolution, and crafting efficient processes
• 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
• Proficiency in Microsoft Office and Vaya systems, to include Excel, data analysis, and secondary research
• Demonstrated knowledge of the assessment and treatment of physical health, behavioral health, intellectual developmental disabilities, without co-occurring mental illness, and substance use issues.
• Ability to use higher-level clinical training and licensure to perform clinical assessments, drive positive outcomes for members, support care management colleagues, and offer clinical assistance to providers
• Experience and knowledge of the NC Medicaid program, NC Medicaid Transformation, Tailored Plans, state-funded services, and accreditation requirements are preferred.
• Have a dynamic, proactive approach to assessment, screening, monitoring and coordination of care, to ensure quality supports and consistent adherence to waiver requirements
• Understand the following areas, in addition to other required trainings:
  • Behavioral Health and Intellectually and Developmentally Disabled (BH I/DD) Tailored Plan eligibility and services
  • Whole-person health and unmet resource needs (Adverse Childhood Experiences (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 information technology (IT), care planning, ongoing coordination)
  • Other care management skills (Transitional care management, motivational interviewing, Person-centered needs assessment and care planning, etc)
  • Serving members and understanding various Behavioral Health (BH), Intellectual/Developmental Disabilities (I/DD) and Traumatic Brain Injury (TBI) diagnoses, Home and Community Based Services (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 Substance Use Disorders (SUD) or with SUD history
  • Serving members with Long-Term Services and Supports (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

Associate Degree in Nursing required.  Bachelor’s Degree in Nursing, Healthcare, or Human Services preferred.  Two (2) or more years of experience working directly with individuals with physical health, behavioral health, IDD, or TBI needs.  Experience in Medicaid Managed Care preferred.

Licensure/Certification Required:

An active and unencumbered RN license.  Must be licensed as a registered nurse in North Carolina.

*Due to the multi-disciplinary nature of the LME/MCO business, care managers must operate within their scope of practice, and must engage and leverage other disciplines outside of their own training and credentials.

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:  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 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 https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.