Tribal Option Care Manager

Cherokee Indian Hospital Authority•Cherokee, NC

3d•Onsite

About The Position

The individual performs care management to individuals of all ages. The Care Manager will complete Care Needs Screenings (CNS) as necessary and will be primarily responsible for completing the Comprehensive Assessment (CA) on eligible members who have identified health needs or gaps in care. The Care Manager will be primarily responsible for assisting the member, develop their care team and the completion of the Care Plan/ISP based on the needs and desires of the member/legally responsible person, team and their support system. Plans will be person centered in nature and reflect all the areas of support needed by the member. The Care Manager will ensure level of care assessments are completed and is responsible for coordinating the member’s whole person care (Physical, Behavioral, pharmacy, BH, LTSS, IDD, TBI, and Unmet Social or Health-Related Resource Needs, including but not limited to vocational, education, social supports, personal safety, housing and food insecurity). The overall goal of the Care Management model is improved health outcomes for eligible individuals. The design of the model has been shaped by the following guiding principles: Broad access to care management. Care Management is available to all eligible individuals continuously, with limited exceptions. Dedicated care manager taking an integrated, whole-person approach. To the maximum extent possible, each enrolled individual will receive integrated, whole-person care management from a dedicated care manager with expertise and training in addressing behavioral health, I/DD, LTSS and/or TBI needs in addition to physical health needs and unmet health-related resource needs. Person and family-centered planning. Care planning for individuals will be person-centered and will consider their unique needs. Parents, other family members, and caregivers can also serve as part of the individual’s care team, with the individual’s consent. Care Management aligns with the North Carolina System of Care framework.

Requirements

Bachelor’s or Associates degree in nursing from an accredited program.
Bachelor’s degree in a field related to health, psychology, sociology, social work, special education, nursing or another relevant human services area
Minimum of two years of nursing/working experience preferred
If applicant is an RN-must have an unrestricted valid Registered Nurse license within the state of North Carolina or a state that is accepted as reciprocity.
Applicant must have a valid North Carolina driver’s license.
Knowledge and ability to independently plan, manage, and organize work in order to meet priorities, accomplish work within established time frames and work in stressful situations.
Knowledge of the occupational functions of multi-disciplinary health care team.
Knowledge of the culture and medical health profile of the member population.
Knowledge and ability to teach and counsel member/family on health maintenance and disease prevention.
Knowledge of available health care programs and community resources.
Knowledge of care management including screenings, assessments, development of care plans and knowledge of resources available to members at all levels including tribal, county, regional and state.
Knowledge of LOC process, SIS for IDD and FASN assessment for TBI
Knowledge of Medicaid basic, enhanced MH/SUD, and waiver benefits plans
Knowledge of and skilled in the use of motivational interviewing and techniques
Strong interpersonal and written/verbal communication skills
Conflict management and resolution skills
Proficient in Microsoft Office products (such as Word, Excel, Outlook, etc.)
Ability to master care management platforms and review data for decision making and person-centered planning
High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance.
Ability to make prompt, independent decisions based upon relevant facts
Good organizational skills to prioritize duties and work with minimal levels of onsite supervision to consistently meet deadlines

Nice To Haves

Specific experience working with Native Americans preferred.
Current Basic Life Support (BLS) minimally required. Can be acquired through the facility within 6 months following appointment to position.

Responsibilities

Utilizes best practice models to identify, incorporate or develop best practices for panel management.
Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies.
Manages assigned panel by addressing and resolving acute care needs and chronic care needs through a team-based approach.
Utilizes the electronic health record to assist with tracking and monitoring the appropriate follow-up of members targeting specific health indicators.
Utilizes the care management platform for documentation of care management functions such as a care needs screening, comprehensive assessment, and care planning.
Utilizes different available platforms/dashboards for population health and related interventions and innovations for management of care needs or gaps in care
Coordinates and follows up on referrals to outside specialty providers, recent ED visits, and ICC visits.
Coordinates and follows up on recent admissions and discharges.
Provides member education, advice and information on health assessment, disease processes, medications, treatment plans and available community resources.
Assesses member needs using established clinical guidelines, protocols, and pathways.
Collects data from relevant sources (member, family, or caregiver) regarding the biological, psychological, social and cultural factors that might influence and impact the health status of the individual and utilizes this data in member center care plan development.
Interprets data and recognizes existing relationships between data collected and the member’s health status and treatment regimen and determines the member’s need for immediate interventions.
Initiates individualized care plan based on assessment of the member for specific illnesses, injuries, and diseases Social Determinants of Health (SDoH) and human behavior while adhering to appropriate standards of care.
Develops individualized plan of care with input from the member, the member’s family, team members, and anyone else the member requests to be included for those members considered “high risk.”
Develops expected member outcomes that are observable and within an adequate period, and are congruent with the member’s present and potential physical capabilities and behavioral patterns.
Responsible for assisting with establishing a multidisciplinary care team for each member.
Coordinates closely with each member’s primary care provider (PCP), and, as appropriate, care manager extenders, assigned County Child Welfare worker, EBCI Family Safety Program staff, CIHA Care Team, family members and guardians to manage the member’s health care needs.
Assumes coordination responsibility for transition planning.
The care manager will make best efforts to contact the member during their stay in an inpatient psychiatric unit or hospital, Facility-Based Crisis, general hospital unit, or nursing facility and make best effort to contact the member on the day of discharge.
Provides transitional care management during care transitions (including assisting individuals with transitioning from congregate or other intensive treatment settings to a foster care home or other community placement).
Obtain a copy of the discharge plan for members being discharged from an inpatient psychiatric unit or hospital, Facility-Based Crisis, or general hospital unit, or nursing facility and review the discharge plan with the member and facility staff.
Facilitate clinical handoffs.
Responsible for ensuring members receive robust medication reconciliation and management.
Assists the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management, and support medication adherence
Directs the extender’s care management functions and ensure that the extender supports allowable activities (e.g., coordinating services/appointments by arranging transportation, etc.).
Responsible for implementing the Healthy Opportunities Pilot (HOP) program for its HOP-eligible members
Facilitates additional requirements for members obtaining 1915(i) services
May be subject to on-call and callback.
May be necessary to work when administrative leave is granted if member care would be compromised.
The incumbent will be evaluated annually on his/her ability to identify, assess, analyze, and evaluate data and solve problems through the CIH Performance Appraisal System.