Tailored Care Manager

Coastal Horizons Center•Wilmington, NC

37d•Hybrid

About The Position

The Tailored Plan Care Manager is an integral part of Coastal Horizons Centers team approach to integrated care for behavioral health and medical care. This role provides direct support to the client through a collaborative role with the Primary Care Provider and Psychiatric Provider. Care Managers interact with all members of the healthcare team to keep the lines of communication open. Their role is to improve positive client outcomes through linking clients to primary care, specialists, dentist, behavioral health care needs, social determinants of health and connecting clients to community resources. Tailored Care manager assists in enhance communication and the continuity of care with their providers and ensures smooth transitions for discharges from inpatient medical, psychiatric, recovery programs or other facilities by coordinating care follow up care and providing medication reconciliation. The TCM will teach, mentor and monitor clients on issues relevant to their care and provide advocacy. This position will serve the New Hanover, Pender and Brunswick counties.

Requirements

A Bachelors degree in a field related to health, psychology, sociology, social work, nursing or another relevant human services area
2 years of experience working directly with individuals with behavioral health condition

Nice To Haves

1 year experience providing care management, case management, or care coordination to the population being served
Commissioner for Case Management Certification (CCM)
trained to provide evidence-based care coordination, brief behavioral interventions, clinical assessments, and to support the treatments such as medications initiated by the Primary Care Provider (PCP)

Responsibilities

Oversight of Care Management services and activities based on care management standards of of practice for enrolled populations.
Develop, review and complete comprehensive assessments that are patient-centered and considers the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual, and cultural needs of the enrolled population, throughout the continuum of care to improve their health outcomes.
Work with clients/caregivers, to identify and address behavioral, social, cultural, and environmental strengths and barriers as it relates to his/her diagnosis, treatment, and access to care.
Implement Care Management interventions, set goals, and develop the plan of care based on transitional care discharge plans/instructions, the comprehensive assessment, and patients goals.
Implement patient-centered plans using therapeutic skills and techniques such as trauma informed care, motivational interviewing, strengths-based, and solution-focused modalities.
Facilitate and provide education to client/family about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self -management
Monitor quality and effectiveness of interventions to the enrolled populations by setting patient-centered SMART goals in collaboration with the patients and families identified goals.
Delegates tasks and referrals to members of the care management team appropriately, accurately and timely according to established workflows.
Serve as an advocate and liaison among the client/family, community services, primary providers, specialists, and other care team members to coordinate services.
Engage and maintain collaborative relationships with community provider agencies that promote quality care and cost-effective health care utilization.
This position includes after-hours coverage on a rotating schedule of approximately one week per month.
Maintain appropriate and timely documentation in the Care Management documentation platform, in accordance with organizational policies and procedures.
Abide by company policies and HIPAA regulations.
Will perform home visits as required by clinical judgment, patient needs and policies and procedures.