We are currently seeking Care Managers (TCL) to serve members in Wake county
The Care Manager l-TCL assures that individuals and families with special health care needs receive integrated whole-person care management, including coordinating across physical health, behavioral health, pharmacy and unmet health-related resource needs to ensure they are linked to services and supports in an effort to maximize potential outcomes and decrease the unnecessary use of hospitals and emergency services by assuring that appropriate quality care is in place.
The Care Manager I – TCL focuses on a specified population of members utilizing health care services while ensuring all member health needs and referrals are attended to. The Care Manager l will collaborate with other community systems to work in partnership to support the identified population.
This position will require travel within the communities Alliance serves for home visits and community contacts. The ability to work remotely will be based on performance.
Responsbilities & Duties
Complete Assessment/Planning
Complete comprehensive assessments or Care Needs Screening at enrollment, yearly or at changes in condition
Develop Plans of Care derived from the completed assessments
Demonstrate commitment to whole person/integrated care
Assign interventions/plans of care to applicable Alliance Care Management team member to meet identified member needs, for monitoring, and/or service engagement activities
Submit referrals to the Care Management Consultant when a physical health or behavioral health need indicates medical and/or pharmaceutical complexity
Assign Plan of Care activities to Community Health Worker if member has identified Social Determinants of Health (SDOH), disparities and/or complex payer issues
Assist individuals/legally responsible persons in choosing service providers; ensuring objectivity throughout the process
Consistently evaluate appropriateness of services and ensure implementation of plan of care through information gathering and assessment at defined frequency of contact based on risk stratification and/or member stated needs
Utilize person centered planning, motivational interviewing, and historical review of assessments in JIVA to gather information and to identify supports needed for the individual
Assist in collecting data to be used to identify and address barriers as well as determine the effectiveness of care management/care coordination in reducing lengths of stay and use of emergency services
Actively collaborate with members/legally responsible person, care team, service providers, and identified supports to ensure development of a plan that accurately reflects the individual’s needs and desired life goals consistent with best practices and working through the permanent supportive housing model
Provide Support and Monitoring to Members
Schedule initial contact with member for purpose of assessment and engagement
Schedule face to face, virtual, and telephonic meeting with member/guardian to provide education about Alliance Health Plan, care teams, resources, and services
Provide education and support, to individuals and LRP, in learning about and exercising rights, explanation of the grievance and appeals process, available service options, providers available to meet their needs, and payer requirements that may impact service connection and maintenance
Refer members who are in crisis/institutional setting and require assistance with returning to community based services to the Integrated Health Consultant or applicable care team member
Recognize and report critical incidents and provider quality concerns to supervisors and Quality Management Department
Complete activities in JIVA related to Plans of Care developed from the Care Management Comprehensive Assessment or other assessments as deemed necessary
Coordinate with other team members to ensure smooth transition to appropriate level of care when needed
Communicate with member to check on status, verify care needs are met and update the Plans of Care, as needed
Provide follow up coordination with key stakeholders to promote engagement
Promote customer satisfaction through ongoing communication and timely follow-up on any concerns/issues
Verify that ongoing service adherence is maintained through monitoring meetings with member and/or guardian or provider
Identify barriers to treatment and assist individuals with arranging appointments or linking to treatment providers
Maintain required contacts with member/legally responsible person per state contractual requirements meeting minimum expectations
Attend community, provider, stakeholder meetings as needed for member and/or as directed to support the needs of the health plan
Complete Documentation
Obtain and upload all supporting documentation, Legally Responsible Person (LRP) verification, and release of information that will improve care management activity on behalf of the member
Open new episodes in JIVA when needed and schedule initial contact with member to verify accuracy of demographic information and initiate the rapport building process
Document all applicable member updates and activities per organizational procedure
Escalate complex cases and cases of concern to immediate supervisor.
Share appropriate documentation with all involved stakeholders as consent to release is granted
Obtain releases/documentation and provide to all stakeholders involved
Maintain medical record compliance/quality
Proactively respond to an individual’s planned movement outside the Alliance geographic area, or other transition need, to ensure a smooth transition without lapse in care.
Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meets state, agency documentation standards, and Medicaid requirements
Compliance with Alliance Policy and Procedure
Adhere to all Alliance Organizational Policies and Procedures and Care Management Desk Procedures
TCL Ongoing Monitoring
Complete TCL monitoring requirements as outlined in service desk reference to support member tenancy, health, safety and community integration, property and provider coordination, technical assistance, service linkage, addressing barriers, review the monthly tenancy checklist and routine reporting
Assist the Post-Transition Engagement Specialist with contact information, as needed, so the 11- month and 24 - month Quality of Life surveys can be completed by their due date
Tenancy Stability/Rehousing
Provide support to Community Health and Well-being Supportive Housing team to secure documents required to maintain TCL tenancy, including annual inspections, biannual recertification, income adjustments, and monthly housing checklist, as needed
Complete and follow up on any voucher application needs
Provide technical assistance to providers during the re-housing process
Complete, at minimum, monthly follow up with providers when a member loses TCL housing and requests to be reshoused
Assist provider with completing the required documents for members moving to Bridge or Hotel Program
Update State and Alliance Health data systems when rehousing is confirmed
Educate member about Individual Placement and Support-Supported Employment (IPS-SE) for employment referral, community integration and education referral and support
Housing Separations
Complete required discharge tasks when member leaves TCL housing
Minimum Requirements
Bachelor’s degree from an accredited college or university in Human Services field and two (2) years of post-bachelor’s degree mh/dd/sa experience with the population served
Or
Bachelor’s degree from an accredited college or university in Non-Human Services field and four (4) years of post-bachelor’s degree mh/dd/sa experience with the population served
Or
Master’s Degree from an accredited college or university in Human Services field and one (1) year of post graduate degree mh/dd/sa experience with the population served
Or
Fully or Provisionally Licensed in the State of North Carolina as a LCSW, LCMHC, LPA, or LMFT
Or
Licensed Registered Nurse (RN) in the State of North Carolina with four (4) years of mh/dd/sa experience with the population served
