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Base pay range
$54,007.00/yr - $70,200.00/yr
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LOCATION: Remote – must live in or near Granville County, North Carolina. The person in this position must maintain residency in North Carolina or within 40 miles of the North Carolina border. This position requires travel.
GENERAL STATEMENT OF JOB
The Care Manager is responsible for providing proactive intervention and coordination of care to eligible Vaya Health members and recipients (“members”) to ensure that these individuals receive appropriate assessment and services. 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 needed by the member across the MH, SU, intellectual/ developmental disability (“I/DD”), traumatic brain injury (“TBI”) physical health, pharmacy, long-term services and supports (“LTSS”) and unmet health-related resource needs networks. Care Managers support and may provide transition planning assistance to state, and community hospitals and residential facilities and track individuals discharged from facility settings 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, including members’ home communities. The Care Manager also works with other Vaya staff, members, relatives, caregivers/ natural supports, providers, and community stakeholders. As further described below, essential job functions of the Care Manager include, but may not be limited to:
Utilization of and proficiency with Vaya’s Care Management software platform/ administrative health record (“AHR”)
Outreach and engagement
Compliance with HIPAA requirements, including Authorization for Release of Information (“ROI”) practices
Performing Health Risk Assessments (HRA): a comprehensive bio-psycho-social 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
Adherence to Medication List and Continuity of Care processes
Participation in interdisciplinary care team meetings, comprehensive care planning, and ongoing care management
Transitional Care Management
Diversion from institutional placement
This position is required to meet NC Residency requirements as defined by the NC Department of Health and Human Services (“NCDHHS” or “Department”). This position is required to live in or near the counties served to effectively deliver in-person contacts with members and their care teams.
ESSENTIAL JOB FUNCTIONS
Assessment, Care Planning, and Interdisciplinary Care Team:
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 (i.e., medical, and behavioral health home).
Meets with members to conduct the HRA and gather information on their overall health, including behavioral health, developmental, medical, and social needs.
Administer the PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings within their scope based on member’s needs. The Care Manager uses these screenings 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, which triggers the creation of a multisource medication list that is shared back with prescribers to promote integrated care.
Supports the care team in development of a person-centered care plan (“Care Plan”) 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.
Ensure the Care Plan includes specific services to address mental health, substance use, medical and social needs as well as personal goals.
Ensure the Care Plan includes all elements required by NCDHHS.
Use information collected in the assessment process to learn about member's needs and assist in care planning.
Ensure members of the care team are involved in the assessment as indicated by the member/LRP and that other available clinical information is reviewed and incorporated into the assessment as necessary.
Work with members to identify barriers and help resolve dissatisfaction with services or community-based interventions.
Reviews clinical assessments conducted by providers and partners with Care Manager - LP and Care Manager Embedded - LP for clinical consultation as needed to ensure all areas of the member’s needs are addressed. Help members refine and formulate treatment goals, identifying interventions, measurements, and barriers to the goals.
Ensures that member/legally responsible person (“LRP”) is/are informed of available services, referral processes (e.g., requirements for specific service), etc.
Provides information to member/LRP regarding their choice of service providers, ensuring objectivity in the process.
Works in an integrated care team including, but not limited to, an RN (Registered Nurse) and pharmacist along with the member to address needs and goals in the most effective way ensuring that member/LRP have the opportunity to decide who they want involved.
Supports and may facilitate care team meetings where member Care Plan is discussed and reviewed.
Solicits input from the care team and monitor progress.
Ensures that the assessment, Care Plan, and other relevant information is provided to the care team.
Reviews assessments conducted by providers and consults with clinical staff as needed to ensure all areas of the member’s needs are addressed.
Other duties as assigned.
EDUCATION & EXPERIENCE REQUIREMENTS
Bachelor’s degree required, preferably in a field related to health, psychology, sociology, social work, nursing or another relevant human services area.
Serving members with BH conditions:
Two (2) years of experience working directly with individuals with BH conditions.
Serving members with LTSS needs:
Two (2) years of prior Long-term Services and Supports (LTSS) and/or Home Community Based Services (HCBS) coordination, care delivery monitoring and care management experience.
This experience may be concurrent with the two years of experience working directly with individuals with BH conditions, an I/DD, or a TBI, described above.
—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 in mental health with population served.
—If graduate of a college or university with a Bachelor's degree in a field other than Human Services, then incumbent must have four years of full‑time accumulated experience in mental health 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 in mental health 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 in mental health with the population served.
*Must meet the criteria of being a North Carolina Qualified Professional with the population served in 10A NCAC 27G .0104
Licensure/Certification Required:
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.
Preferred work experience
Experience working directly with individuals with I/DD or TBI.
RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.
SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.
APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.
Vaya Health is an equal opportunity employer.
Medical insurance
Vision insurance
401(k)
Pension plan
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