Care Coordinator/Extender

MEDNORTH HEALTH CENTER•Wilmington, NC

5d•Onsite

About The Position

The Tailored Plan Care Manager Extender is an integral part of MedNorth Health Center’s team approach to integrated care for patients with Intellectual or Developmental Disabilities (I/DD) and/or Behavioral Health challenges (severe and persistent mental health and/or substance use diagnoses). The Tailored Plan Care Manager Extender provides direct support to the patient under the direction of the Care Manager and as a part of the patient’s overall care team. This position will serve primarily New Hanover County with some patients in the surrounding counties.

Requirements

At least 18 years of age
A high school diploma or equivalent (e.g., GED, certificate of completion)
Meet one of the following requirements:
Be a person with lived experience with an I/DD or a TBI with demonstrated knowledge of and direct personal experience navigating the North Carolina Medicaid delivery system.
Be a person with lived experience with a behavioral health condition who is a Certified Peer Support Specialist.
A parent or guardian of an individual with an I/DD or a TBI or a behavioral health condition and has at least two years of direct experience providing care for and navigating the Medicaid delivery system on behalf of that individual (note that a parent/guardian cannot serve as an extender for their family member).
Has two years of paid experience performing the types of functions described in the “Extender Functions” section below, with at least one year of paid experience working directly with the Tailored Care Management eligible population.
The individual will be able to meet these qualifications, including, but not limited to:
Certified Peer Support Specialists
Community health workers (CHW), defined as individuals who have completed the NC Community Health Worker Standardized Core Competency Training (NC CHW SCCT);
Individuals who served as Community Navigator or care coordinators prior to the implementation of Tailored Plans;
Parents/guardians or immediate family member of an individual with an I/DD or a TBI or a behavioral health condition (parent/guardian cannot serve as an extender for their own family member).
Strong interpersonal and written/verbal communication skills
Conflict management and resolution skills
High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance.
Strong problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers.
Ability to organize multiple tasks and priorities
Ability to change the focus of activities to meet changing priorities
Ability to speak English fluently.
Must demonstrate flexibility and adaptability.

Nice To Haves

Knowledge of Medicaid basic, enhanced MHSUD, and waiver benefits plans
Knowledge of community specific financial planning resources
Knowledge of regulations and statutes specific to 1915(b) and (c) waiver services including licensure type required for facility-based services, and staffing and supervision requirements (LTS and TBI Care Workers only)
Knowledge of and skilled in the use of Motivational Interviewing techniques
Detail oriented
Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is strongly preferred
The ability to speak other languages is a plus.

Responsibilities

Interact with all members of the healthcare team to keep the lines of communication open.
Improve positive patient outcomes through linking patients to medication management, coordinating patient physical, developmental and behavioral health care needs, educating patients, building trust between patients and their practitioners, supporting and connecting patients to community programs and enhancing communication and the continuity of care
Provide appropriate documentation in the patient record.
Access EHR’s to obtain and upload into the care management platform
Access Hospital data and/or Electronic Medical Record system will be required, as necessary
Consult with corresponding multi-disciplinary care team members to coordinate the services identified in patient’s care plan to include addressing any barriers to social determinants of health and addressing any unmet needs.
Work with the family and friends of the patient and anyone else involved in caring for the patient to ensure proper care is provided
Perform general outreach, engagement and follow-up with patients
Assist with mailing educational materials, consent forms or other documents to the patient as necessary
Coordinate services, referrals, and appointments (appointment reminders, arranging transportation, etc)
Provide and track referrals and provide information and assistance to patients to assist them in obtaining and maintaining community-based resources and social support services
Provide culturally appropriate health education and information
Engage in health promotion activities and knowledge sharing
Share information with the care manager and other members of the care team on patient’s circumstances
Support the care manager in assessing and addressing unmet health-related resource needs
Advocate for patients and their families
Notify Care Manager of any new service needs identified during service monitoring and participate in case conferences
Identify care gaps and perform outreach to patients in attempt to close gaps as requested
Abide by department guidelines, company policies, and HIPAA regulations
Transport patients and/or materials to patients
Engage in various trainings and skill-building activities such as learning how to obtain and maintain stable housing, manage finances, increase employment readiness skills, interact with others in private and public settings, maintain healthy non-violent relationships, engage in safe, non-medical ways to control modifiable risk factors that impact his or her health (e.g. smoking, drug and alcohol use, obesity, etc.) and learn skills to increase motivation and actively address health conditions such as diabetes, heart disease, COPD, etc.
Develop in-depth knowledge of various community systems and provide consultation
Build partnerships with public and private mental health agencies, child serving agencies, DSS, DJJ, and community partners, to develop programs and resources to increase family involvement in care delivery.
Willingly performs other duties as assigned.
Each staff member is a member of the Patient Centered Medical Home model and you are required to work as part of a team to provide high-quality, patient-focused care. Your role is to help ensure patients have timely access to services, support coordinated care by communicating effectively with team members and patients, and contributing to quality improvement efforts. Your commitment to respectful, compassionate service and teamwork is required to help us meet PCMH standards, improve patient outcomes, and maintain a supportive care environment.
It is an essential job element that everyone be compliant with the full law and fully cooperate with the compliance program without fear of retaliations from the organization.