LOCATION: Remote - Buncombe County, NC

GENERAL STATEMENT OF JOB:

The Mental Health/Substance Use (MHSU) Care Manager, hereafter referred to as care manager, is responsible for providing proactive intervention and coordination of care to eligible members and recipients of Vaya’s Health plan to ensure that these individuals receive appropriate assessment and services. This Care Manager does not provide Home and Community Based Services (HCBS) Waiver care coordination. The Care Manager 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 across the MH/SU/IDD and other healthcare network(s) with existing or new care team members. Care Managers support and may provide clinical transition planning assistance to local hospitals and tracks individuals discharged from state and community hospitals 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. The Care Manager may work with members in their home communities. The Care Managers also works with other Vaya staff, members and family members, providers as well as community stakeholders. Essential job functions of the Care Managers include, but may not be limited to:

• CM Platform basics
• Outreach & Engagement
• Release of Information practices
• Health Risk Assessment
• Medication List and Continuity of Care process
• Care Planning
• Interdisciplinary Care Team and Ongoing Care Management
• Transitoinal Care Management
• Diversion

Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

ESSENTIAL JOB FUNCTIONS:

Assessment, Care Planning and Interdisciplinary Care Team:

• Ensure identification, assessment and appropriate Person Centered Care Planning for members identified as having Special Health Care Needs or as High Risk High Cost members (as supported by state funds) or other Care Management populations and link appropriate formal/ informal services and supports (i.e. medical and behavioral health home)
• Meet with members to conduct a comprehensive bio-psycho-social assessment in order to gather information on their overall health, including behavioral health, developmental, medical and social needs
  1. Health Risk Assessment (HRA) is a comprehensive assessment addressing social determinants of health, mental health history and needs, physical health history and needs, activities of daily living, access to resources, and other areas to ensure a whole person approach to care
• May administer the PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings within their scope based on member’s needs
  1. Scores are calculated and reviewed allowing MH/SU Care Manager to provide specific education and self-management strategies as well as linkage to appropriate therapeutic supports. The assessment process includes reviewing and transcribing member’s current medication and entering information into Vaya’s Care Management platform to trigger the continuity of care process which results in the creation of a multisource medication list that is shared back with prescribers to promote integrated care.
• Use assessment to learn about member's needs to aide in care planning,
• Create a person-centered care plan for members to help define what is important to members for their health and prioritize goals that help them live the life they want in the community of their choice and ensure Care Plan includes specific services to address mental health, substance use, medical and social needs as well as personal goals
  1. Care Plans are created based on information collected in the assessment process
  2. Ensure members of the care team are involved as indicated by the member/guardian(s) and that other available clinical information is reviewed and incorporated into the assessment as necessary
  3. Work with members to mediate dissatisfaction within the community
• Assist members in refining and formulating treatment goals, identifying interventions, measurements and barriers to the goals
• Ensures that member/guardian(s) is/are informed of available services, referral processes (e.g., requirements for specific service), etc.
• Provide information to member/guardian(s) regarding their choice in choosing service providers, ensuring objectivity in the process
• Work in an integrated care team including, but not limited to, an RN and pharmacist along with the member to address needs and goals in the most effective way ensuring that member/guardian(s) have the opportunity to decide who they want involved
• Coordinates and may facilitate Care Team meetings where member Care Plan is discussed and reviewed
• Solicit input from the care team and monitor progress
• Ensures that the assessment, care plan and other relevant information is provided to the care team as indicated in Vaya policy and necessary Care Plan elements are included
• Review assessments conducted by providers and consult with clinical staff as needed to ensure all areas of the member’s needs are addressed
• Update Care Plans and Care Management assessment at a minimum of annually or when there is a significant life change for the member
• Conducts education and referral to prevention and population health management programs.
• Create a Care Management Crisis Plan which is separate and complimentary to the behavioral health provider’s crisis plan
  1. Collaborate with members to develop a Crisis Plan that is tailored to their needs and desires
• Conducts Transitional Care Management responsibilities
• Coordinates Diversion efforts for members at risk of requiring care in an institutional setting
• Link members to necessary services and supports across all health domains.

Collaboration, Coordination, Documentation:

• 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 DSS, DJJ, CCNC, school systems, and other community stakeholders as appropriate.
• Works in partnership with other Vaya departments to address identified needs within the catchment.
• CM may participate in cross-functional clinical and non-clinical meetings and other projects to support the department and organization.
• Participate in routine multidisciplinary huddles including RN, Pharmacist, M.D. to present complex clinical case presentation and needs, providing support to other CM’s and receiving support and feedback regarding CM interventions for clients’ medical, behavioral health, intellectual /developmental disability, medication, and other needs.
• CM participates in other high risk multidisciplinary complex case staffing’s as needed to include Vaya Medical Director, Utilization Management, Provider Network, and Care Management leadership to address barriers, identify need for specialized services to meet client needs within or outside the current behavioral health system.
• Ensure quality care, health/safety of the individual, as well as the continued appropriateness of services
• Monitor services for compliance with standards
• Promote problem-solving and goal-oriented partnership with member/guardian(s), providers, etc. and recognize and report critical incidents
• Promote satisfaction through ongoing communication and timely follow-up on any concerns/issues
• Educate members/families on services and resources.
• Verify member continuing eligibility for Medicaid
• Promptly follow-up on issues
• Proactively responds to an member’s planned movement outside the Vaya’s geographic area to ensure changes in their Medicaid County of eligibility are addressed prior to any loss of service
• Maintain electronic health record compliance/quality according to Vaya policy
• Proactively monitor own documentation to ensure that issues/errors are resolved as quickly as possible
• Ensure all clinical and non-clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency and Medicaid requirements
• Participate in and maintain Care Management and Vaya trainings and proficiencies

Other duties as assigned.

QUALIFICATIONS & CREDENTIALING REQUIREMENTS:

Bachelor's Degree in a field related to health, psychology, sociology, social work, nursing or another relevant human services area or licensure as an RN* (see licensure section) and the following experience:

• Serving members with BH conditions:
  • Two (2) years of experience working directly with individuals with BH conditions
• Serving members or recipients with an I/DD or Traumatic Brain Injury (TBI)
  • Two (2) years of experience working directly with individuals with I/DD or TBI
• Serving members with LTSS needs
  • Minimum requirements defined above

PHYSICAL REQUIREMENTS:

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.
• Ability to drive and sit for extended periods of time (including in rural areas)

KNOWLEDGE OF JOB:

• Ability to express ideas clearly/concisely
• Ability to drive and sit for extended periods of time (including in rural areas)
• Represent Vaya in a professional manner

• An ability to initiate and build relationships with people in an open, friendly, and accepting manner
• Ability to take ownership of projects from planning through execution
• Strong attention to detail and superior organizational skills
• Ability to multitask and prioritize to manage multiple projects on tight timelines
• Ability to understand the strategic direction and goals of the department and support appropriate processes to facilitate achievement of business objectives
• Well-developed capabilities in problem solving, negotiation, conflict resolution, and crafting efficient processes
• 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
• Proficiency in Microsoft Office and Vaya systems, to include Excel, data analysis, and secondary research
• Demonstrated knowledge of the assessment and treatment of developmental disabilities, without co-occurring mental illness
• Have highly effective communication
• Employee will participate in and maintain Care Management and Vaya trainings and proficiencies as required.
• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance.
• This will require exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts.
• Problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers.
• Must be highly skilled at shifting between macro and micro level planning, maintaining both the big picture, and seeing that the details are covered.
• Care Managers must exhibit an extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) and have considerable knowledge of the MH/SU/DD service array provided through the network of Vaya providers.
• Additional knowledge in Vaya Medicaid B and C waivers and accreditation is essential.
• The employee must be detail oriented, able to organize multiple tasks and priorities, and to effectively manage projects from start to finish.
• Work activities quickly change according to mandated changes and changing priorities within the department.
• The employee must be able to change the focus of his/her activities to meet changing priorities.
• Training, learning, and proficiency are tracked through the Care Management Training Matrix and any other required means.
• Training may be delivered in a variety of methods and forums.
• Care Managers must understand the following areas, in addition to other required trainings:
  • BH I/DD Tailored Plan eligibility and services
  • Whole-person health and unmet resource needs (ACEs, Trauma, cultural humility)
  • Community integration (Independent living skills; transition and diversion, supportive housing, employment, etc.)
  • Components of Health Home Care Management (Health Home overview, working in a multidisciplinary care team, etc.)
  • Health promotion (Common physical comorbidities, self-management, use of IT, care planning, ongoing coordination)
  • Other care management skills (Transitional care management, motivational interviewing, Person-centered needs assessment and care planning, etc.)
  • Serving members with I/DD or TBI (Understanding various I/DD and TBI diagnoses, HCBS, Accessing assistive technologies, etc.)
  • Serving children (Child- and family-centered teams, Understanding of the “System of Care” approach)
  • Serving pregnant and postpartum women with SUD or with SUD history
  • Serving members with LTSS needs (Coordinating with supported employment resources
• Care Managers should be proficient in the aforementioned essential job functions. Job functions with higher consequences of error may be identified, and proficiency demonstrated and measured through job simulation exercises administered by the supervisor where a minimum threshold is required of the position.
• In addition, MHSU CM must have thorough knowledge of standard office practices, procedures, equipment, and techniques and have intermediate to advanced proficiency in Microsoft office products (Word, Excel, Power Point, Outlook, Teams, etc.)

LICENSURE:

*If RN, licensure as an North Carolina RN (see education section)

LOCATION REQUIREMENT:

In accordance with the BH and I/DD Tailored Plan requirements mandated by the NC Department of Health and Human Services, certain Vaya Health positions are required to be filled by individuals who reside in North Carolina, meaning someone who establishes a legal domicile in North Carolina and pays income tax in North Carolina, or resides within 40 miles of the North Carolina border. New hires from outside of North Carolina will have 60 days from the date of hire to meet this requirement, if applicable to the position.

This position is required to reside in North Carolina or within 40 miles of the North Carolina Boarder.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open until filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit http://www.vayahealth.com/careers-overview/ Ind.001

Vaya Health is an equal opportunity employer.