Innovations Care Manager (Buncombe County, NC)

Vaya Health•Asheville, NC

15h•Hybrid

About The Position

The Innovations Care Manager (Innovations CM) is responsible for providing proactive intervention and coordination of care to eligible Vaya Health members and recipients to ensure they receive appropriate assessment and services. The Innovations CM works with the member and care team to 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 various networks including MH, SU, I/DD, TBI, physical health, pharmacy, LTSS, and unmet health-related resource needs. Innovations CMs 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’ homes. The Innovations CM also works with other Vaya staff, members, relatives, caregivers, providers, and community stakeholders. Essential job functions include utilization of Vaya’s Care Management software, outreach and engagement, compliance with HIPAA and ROI practices, performing comprehensive bio-psycho-social Health Risk Assessments (HRA), adherence to medication and continuity of care processes, participation in interdisciplinary care team meetings, comprehensive care planning, ongoing care management, transitional care management, and diversion from institutional placement. This position requires meeting NC Residency requirements and living in or near the counties served to effectively deliver in-person contacts.

Requirements

Bachelor’s degree in a field related to health, psychology, sociology, social work, nursing or another relevant human services.
Two (2) years of experience working directly with individuals with I/DD or TBI.
Two (2) years of prior Long-term Services and Supports and/or Home Community Based Services coordination, care delivery monitoring and care management experience.
This experience may be concurrent with the two years of experience working directly with individuals with BH conditions, an I/DD, or a TBI.
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 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 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 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 with the population served.
Must meet the criteria of being a North Carolina Qualified Professional with the population served in 10A NCAC 27G .0104.
If incumbent has a Bachelor’s Degree in nursing and RN, incumbent must be licensed by the North Carolina Board of Nursing to practice in the State of North Carolina.
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.
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.
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 considerable knowledge of the MH/SU/IDD/TBI service array provided through the network of Vaya providers.
Ability to complete and maintain all trainings and proficiencies required by Vaya, including but not limited to: BH I/DD Tailored Plan eligibility and services, Whole-person health and unmet resource needs, Community integration, Components of Health Home Care Management, Health promotion, Other care management skills, Serving members with I/DD or TBI, Serving children, Serving pregnant and postpartum women with Substance Use Disorder (SUD) or with SUD history, Serving members with LTSS needs.

Nice To Haves

Experience and knowledge of the NC Medicaid program, NC Medicaid Transformation, Tailored Plans, state-funded services, and accreditation requirements are preferred.

Responsibilities

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.
Meets with members to conduct the HRA and gather information on their overall health, including behavioral health, developmental, medical, and social needs.
Administers screenings such as PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and others as needed to provide education, self-management strategies, and linkage to appropriate therapeutic supports.
Reviews and transcribes member’s current medication and enters information into Vaya’s Care Management platform to create a multisource medication list shared with prescribers.
Supports the care team in developing a person-centered care plan to help members define what is important to them for their health and prioritize goals.
Ensures the Care Plan includes specific services to address mental health, substance use, medical, and social needs, as well as personal goals, and meets all NCDHHS requirements.
Uses assessment information to understand member's needs and assist in care planning.
Ensures care team members are involved in the assessment as indicated by the member/LRP and that other available clinical information is reviewed and incorporated.
Works with members to identify barriers and resolve dissatisfaction with services or community-based interventions.
Reviews clinical assessments conducted by providers and partners with Innovations CM, LP and Manager, IDD Care Management, LP or Director, Care Management for clinical consultation as needed.
Helps members refine and formulate treatment goals, identifying interventions, measurements, and barriers.
Ensures that member/legally responsible person (LRP) is informed of available services, referral processes, and requirements for specific services.
Provides information to member/LRP regarding their choice in choosing service providers, ensuring objectivity.
Works in an integrated care team including an RN and pharmacist, along with the member, to address needs and goals.
Supports and may facilitate Care Team meetings where the member Care Plan is discussed and reviewed.
Solicits input from the care team and monitors 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.
Updates Care Plans and Care Management assessments 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.
Participates in multidisciplinary huddles to present cases, address barriers, identify needs for specialized services, and receive support and feedback.
Proactively ensures that individuals identified as a Special Needs enrollee with treatment needs or requiring regular monitoring have a Behavioral Health Clinical Home and a Medical Home.
Works with the member/LRP and care team to ensure the development of a Care Management Crisis Plan tailored to the member's needs and desires.
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, supervisors, and colleagues as needed.
Manages and facilitates Child/Adult High-Risk Team meetings in collaboration with providers, stakeholders, and other community supports.
Participates in cross-functional clinical and non-clinical meetings and other projects as needed/ requested.
Works in partnership with other Vaya departments to identify and address gaps in services/ access to care.
Works with Innovations CM, LP and IDD Manager- LP in participating in other high risk multidisciplinary complex case staffing as needed.
Ensures the health and safety of members receiving care management, recognizes and reports critical incidents, and escalates concerns about health and safety.
Ensures that services are monitored (including direct observation of service delivery) in all settings at required frequency and for compliance with standards.
Makes announced/unannounced monitoring visits, including nights/weekends as applicable.
Monitors provision of services to informally measure quality of care delivered by providers and identify potential non-compliance with standards.
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.
Educates members/families on methodology for budget development, total dollar value of the budget, and mechanisms available to modify the individual budget.
Monitors services to ensure they are delivered as outlined in the individualized service plan and addresses any deviations.
Ensures that service orders/doctor’s orders are obtained, as applicable.
Verifies member’s continuing eligibility for Medicaid and proactively responds to planned movement outside Vaya’s catchment area.
Alerts supervisor and other appropriate Vaya staff if there is a change in member Medicaid eligibility/status.
Proactively and timely creates and monitors documentation within the AHR to ensure completeness, accuracy, and follow-through on care management tasks.
Coordinates Medicaid deductibles, as applicable, with the individual/guardian and provider(s).
Proactively monitors own documentation to ensure that issues/errors are resolved as quickly as possible.
Ensures accurate/timely submission of Service Authorization Requests (SARS) for all Vaya funded services/supports.
Works with Innovations CM, LP and Manager, Innovations Care Management, LP to ensure all clinical and non-clinical documentation meets all applicable federal, state, and Vaya requirements.
Participates in all required Vaya/ Care Management trainings and maintains all required training proficiencies.