Tribal Option Care Manager

Cherokee Indian Hospital Authority•Cherokee, NC

7d•Onsite

About The Position

The Tribal Option Care Manager provides care management to individuals of all ages, completing Care Needs Screenings as needed and Comprehensive Assessments for eligible members with identified health needs or gaps in care. The role helps members develop care teams and person-centered Care Plans or Individual Support Plans that reflect the needs and preferences of the member or legally responsible person, the team, and the member’s support system. The Care Manager ensures level-of-care assessments are completed and coordinates whole-person care across physical and behavioral health, pharmacy, long-term services and supports, intellectual or developmental disabilities, traumatic brain injury, and unmet social or health-related resource needs, including vocational, educational, social support, personal safety, housing, and food needs. The care management model aims to improve health outcomes through broad access, dedicated integrated care management, and person- and family-centered planning. The Care Manager manages an assigned member panel, uses clinical guidelines and available health information platforms to identify needs and gaps in care, coordinates referrals and transitions, provides education and resource information, and collaborates with members, families, providers, and community partners. The role also supports medication reconciliation and adherence, directs care management extenders, implements the Healthy Opportunities Pilot for eligible members, and facilitates requirements for members receiving 1915(i) services. The position operates independently within established procedures and under the supervision of the HOP Supervisor, Assistant Director of Care Management, and Director of Care Management. Work is evaluated for technical soundness and compliance with professional standards. The role requires maintaining strict confidentiality and following applicable policies, procedures, and regulations. Work is primarily in a clinic setting and is mostly sedentary, but includes walking, standing, bending, pushing, and lifting. The incumbent may encounter communicable diseases and other workplace hazards and must follow applicable safety precautions. Flexible working hours may be required, and the position may be subject to on-call and callback.

Requirements

Bachelor’s or associate degree in nursing from an accredited program, or a bachelor’s degree in a field related to health, psychology, sociology, social work, special education, nursing, or another relevant human services area.
If an RN, hold an unrestricted, valid Registered Nurse license in North Carolina or a state accepted for reciprocity.
Current Basic Life Support (BLS); may be acquired through the facility within six months of appointment.
Valid North Carolina driver’s license.
Knowledge of multidisciplinary health care team functions, the member population’s culture and medical health profile, health care programs, community resources, and care management practices.
Knowledge of level-of-care processes, SIS for IDD, FASN assessment for TBI, and Medicaid basic, enhanced MH/SUD, and waiver benefits plans.
Skill in motivational interviewing and techniques, interpersonal and written and verbal communication, conflict management, and resolution.
Proficiency with Microsoft Office products, such as Word, Excel, and Outlook.
Ability to learn care management platforms, review data for decision-making and person-centered planning, and independently plan and organize work.
Ability to prioritize competing tasks, meet deadlines, work in stressful situations, make prompt independent decisions, and work with minimal onsite supervision.
Diplomacy and discretion to negotiate and resolve issues with minimal assistance.
Ability to teach and counsel members and families on health maintenance and disease prevention.

Nice To Haves

At least two years of nursing or other work experience preferred.
Specific experience working with Native Americans preferred.

Responsibilities

Complete Care Needs Screenings as needed and Comprehensive Assessments for eligible members with identified health needs or gaps in care.
Assist members in developing care teams and person-centered Care Plans or Individual Support Plans based on their needs and preferences.
Ensure level-of-care assessments are completed and coordinate members’ whole-person care.
Use best-practice models and collaborate with other teams on health promotion, disease prevention, and panel management strategies.
Manage an assigned member panel by addressing acute and chronic care needs through a team-based approach.
Use the electronic health record, care management platforms, dashboards, and other available tools to track members, document care management functions, monitor health indicators, and address gaps in care.
Coordinate and follow up on specialty referrals, emergency department and ICC visits, hospital admissions, and discharges.
Provide members with education and information about health assessments, disease processes, medications, treatment plans, and community resources.
Assess member needs using established clinical guidelines, protocols, and pathways.
Collect and interpret biological, psychological, social, and cultural information from members, families, and caregivers to inform care planning and identify the need for immediate intervention.
Develop individualized care plans and observable, time-appropriate member outcomes, including plans for high-risk members with input from members, families, team members, and others requested by the member.
Assist in establishing a multidisciplinary care team for each member.
Coordinate with primary care providers and, as appropriate, care manager extenders, County Child Welfare workers, EBCI Family Safety Program staff, CIHA Care Team members, families, and guardians.
Coordinate transition planning, make best efforts to contact members during qualifying inpatient or facility stays and on the day of discharge, and provide transitional care management.
Obtain and review discharge plans with members and facility staff and facilitate clinical handoffs.
Ensure robust medication reconciliation and management, assist members in obtaining medications before discharge, and support medication adherence.
Direct care management functions performed by extenders and ensure they support allowable activities, such as coordinating services and arranging transportation.
Implement the Healthy Opportunities Pilot for eligible members and facilitate additional requirements for members receiving 1915(i) services.
Work when administrative leave is granted if member care would otherwise be compromised.
Maintain confidentiality, comply with applicable regulations and policies, and provide consistently excellent customer service.