Innovations Care Manager (Cherokee County, NC)

Vaya Health•Murphy, NC

19d•$54,007 - $70,209•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 across various networks including MH, SU, I/DD, TBI, physical health, pharmacy, LTSS, and unmet health-related resources. This role supports and may provide transition planning assistance to hospitals and residential facilities, tracking individuals discharged to ensure follow-up with aftercare services and prevent re-hospitalization. This is a mobile position requiring work in various locations, including members' homes, and involves collaboration with Vaya staff, members, caregivers, providers, and community stakeholders. Key functions include utilizing Vaya’s Care Management software, outreach and engagement, HIPAA compliance, performing comprehensive bio-psycho-social Health Risk Assessments (HRAs), adhering to medication and continuity of care processes, participating in care team meetings and planning, transitional care management, and diversion from institutional placement. The position requires meeting NC Residency requirements and living in or near served counties for effective in-person contact.

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.
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.

Nice To Haves

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

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, using results for education, self-management strategies, and linkage to therapeutic supports.
Reviews and transcribes member’s current medication, entering 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 health priorities and achieve community living goals.
Ensures the Care Plan includes specific services for mental health, substance use, medical, and social needs, as well as personal goals and all NCDHHS required elements.
Uses assessment information to assist in care planning and ensures care team involvement as indicated by the member/LRP.
Works with members to identify barriers and resolve dissatisfaction with services or community-based interventions.
Reviews clinical assessments by providers and partners with clinical staff for consultation as needed to ensure all member needs are addressed.
Helps members refine treatment goals, identifying interventions, measurements, and barriers.
Ensures member/legally responsible person (LRP) is informed of available services, referral processes, and provider choice options.
Works in an integrated care team including RN and pharmacist, along with the member, to address needs and goals effectively.
Supports and may facilitate Care Team meetings where member Care Plans are discussed and reviewed.
Solicits input from the care team and monitors progress.
Ensures assessment, care plan, and relevant information are provided to the care team.
Updates Care Plans and Care Management assessments at least annually or upon significant life changes.
Supports and assists with education and referral to prevention and population health management programs.
Participates in multidisciplinary huddles with RN, Pharmacist, M.D., and case staff to present cases, address barriers, identify needs for specialized services, and receive support.
Proactively ensures individuals identified as Special Needs enrollees 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 tailored Care Management Crisis Plan.
Provides crisis intervention, coordination, and care management if needed in the community.
Supports Transitional Care Management responsibilities for members transitioning between levels of care.
Coordinates Diversion efforts for members at risk of institutional care.
Consults with care management licensed professionals, supervisors, and colleagues as needed.
Serves as a collaborative partner in identifying system barriers through work with community stakeholders.
Manages and facilitates Child/Adult High-Risk Team meetings in collaboration with providers, stakeholders, and community supports.
Participates in cross-functional clinical and non-clinical meetings and other projects as needed.
Works in partnership with other Vaya departments to identify and address gaps in services/access to care.
Works with leadership to address barriers and identify needs for specialized services within or outside the current behavioral health system.
Ensures the health and safety of members receiving care management, recognizes and reports critical incidents, and escalates concerns.
Ensures services are monitored (including direct observation) in all settings at required frequency and for compliance with standards.
Makes announced/unannounced monitoring visits, including nights/weekends as applicable.
Monitors service provision to informally measure quality of care and identify potential non-compliance.
Supports problem-solving and goal-oriented partnership with member/LRP, providers, and other stakeholders.
Promotes member satisfaction through ongoing communication and timely follow-up.
Supports and assists members/families on services and resources by using educational opportunities.
Educates members/families on methodology for budget development, total dollar value of the budget, and mechanisms to modify the individual budget.
Monitors services to ensure they are delivered as outlined in the individualized service plan and addresses deviations.
Ensures 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 to ensure changes in Medicaid County of eligibility are addressed prior to any loss of service.
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 for 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 issues/errors are resolved quickly.
Ensures accurate/timely submission of Service Authorization Requests (SARS) for all Vaya funded services/supports.
Ensures 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.
Other duties as assigned.