MHSU Care Manager (Alexander County)
Company: Vaya Health
Location: Taylorsville
Posted on: April 16, 2024
Job Description:
LOCATION: Remote - must live in or near Alexander County
GENERAL STATEMENT OF JOBThe Mental Health/Substance Use ("MHSU")
Care Manager ("MHSU 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 MHSU
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. MHSU 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
MHSU 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 MHSU Care Manager includes, 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 placementThis position is required
to meet NC Residency requirements as defined by the NC Department
of Health and Human Services ("NCDHHS" or "Department"). ESSENTIAL
JOB FUNCTIONSAssessment, 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
MHSU 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 MHSU Care Manager, LP and MHSU 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
- Updates Care Plans and Care Management assessment at a minimum
of annually or when there is a significant life change for the
member
- Supports and assists with education and referral to prevention
and population health management programs.
- Works with the member/LRP and care team to ensure the
development of a Care Management Crisis Plan for the member that is
tailored to their needs and desires, which is separate and
complementary to the behavioral health provider's crisis plan.
- Provides crisis intervention, coordination, and care management
if needed while with members in the community.
- Supports Transitional Care Management responsibilities for
members transitioning between levels of care
- Coordinates Diversion efforts for members at risk of requiring
care in an institutional setting
- Consults with care management licensed professionals, care
management supervisors, and other colleagues as needed to support
effective and appropriate member care. 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 identify
and address gaps in services/ access to care within Vaya's
catchment.
- Participates in cross-functional clinical and non-clinical
meetings and other projects as needed/ requested to support the
department and organization.
- Participates in routine multidisciplinary huddles including RN,
Pharmacist, M.D. to present complex clinical case presentation and
needs, providing support to other CMs (Care Manager) and receiving
support and feedback regarding CM interventions for clients'
medical, behavioral health, intellectual /developmental disability,
medication, and other needs.
- Works with MHSU Care Manager, LP and MHSU Care Manager
Embedded, LP to in participating in other high risk
multidisciplinary complex case staffing as needed to include Vaya
CMO/ Deputy CMO, 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.
- Monitors provision of services to informally measure quality of
care delivered by providers and identify potential non-compliance
with standards.
- Ensures the health and safety of members receiving care
management, recognize and report critical incidents, and escalate
concerns about health and safety to care management leadership as
needed.
- Supports problem-solving and goal-oriented partnership with
member/LRP, providers, and other stakeholders.
- Promotes member satisfaction through ongoing communication and
timely follow-up on any concerns/issues.
- Supports and assists members/families on services and resources
by using educational opportunities to present information.
- Verifies member's continuing eligibility for Medicaid, and
proactively responds to a member's planned movement outside Vaya's
catchment area to ensure changes in their Medicaid County of
eligibility are addressed prior to any loss of service.
- Proactively and timely creates and monitors documentation
within the AHR to ensure completeness, accuracy and follow through
on care management tasks.
- Maintains electronic AHR compliance and quality according to
Vaya policy.
- Works with MHSU Care Manager, LP and MHSU Care Manager
Embedded, LP to ensure all clinical and non-clinical documentation
(e.g., goals, plans, progress notes, etc.) meet all applicable
federal, state, and Vaya requirements, including requirements
within Vaya's contracts with NCDHHS.
- Participates in all required Vaya/ Care Management trainings
and maintains all required training proficiencies. Other duties as
assigned KNOWLEDGE, SKILL & ABILITIES:
- Ability to express ideas clearly/concisely and communicate in a
highly effective manner
- Ability to drive and sit for extended periods of time
(including in rural areas)
- Effective interpersonal skills and ability to represent Vaya in
a professional manner
- Ability to initiate and build relationships with people in an
open, friendly, and accepting manner
- Attention to detail and satisfactory organizational skills
- Ability to make prompt independent decisions based upon
relevant facts.
- Well-developed capabilities in problem solving, negotiation,
arbitration, and conflict resolution, including a high level of
diplomacy and discretion to effectively negotiate and resolve
issues with minimal assistance.
- 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
- Thorough knowledge of standard office practices, procedures,
equipment, and techniques and intermediate to advanced proficiency
in Microsoft office products (Word, Excel, Power Point, Outlook,
Teams, etc.), and Vaya systems, to include the care management
platform, data analysis, and secondary research
- Understanding of the Diagnostic and Statistical Manual of
Mental Disorders (current version) within their scope and have
considerable knowledge of the MH/SU/IDD/TBI service array provided
through the network of Vaya providers.
- Experience and knowledge of the NC Medicaid program, NC
Medicaid Transformation, Tailored Plans, state-funded services, and
accreditation requirements are preferred.
- Ability to complete and maintain all trainings and
proficiencies required by Vaya, however delivered, including but
not limited to the following:
- BH I/DD Tailored Plan eligibility and services
- Whole-person health and unmet resource needs (ACEs,
trauma-informed care, 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 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
- 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. QUALIFICATIONS & EDUCATION
REQUIREMENTSBachelor's degree in a field related to health,
psychology, sociology, social work, nursing or another relevant
human services area is preferred. One of the following years of
experience:
- 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-tern Services and Supports and/or
Home Community Based Services 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 *Must meet the criteria of being a
North Carolina Qualified Professional with the population served in
10A NCAC 27G .0104 OR a combination of education and experience as
follows:Meet North Carolina's Qualified Professional Definition: If
graduate of a college or university with a Bachelor's degree is in
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
is needed to reach QP status, the incumbent must still have at
least two years of experience with the population served.
Licensure/Certification Required:If Bachelor's degree in nursing
and RN, incumbent must be licensed to practice in the State of
North Carolina by the North Carolina Board of Nursing.
Keywords: Vaya Health, Hickory , MHSU Care Manager (Alexander County), Executive , Taylorsville, North Carolina
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