Complex Care Consultants address the co-occurring complex medical and functional needs for members transitioning out of Adult Care Homes (ACH) and into the community and facilitate the provision of essential services needed to allow Transition to Community Living (TCL) individuals to make and sustain an effective transition from ACHs to community-based supported housing.
This position will require regular visits with members in Adult Care Homes and with members living in the community, resulting in significant travel.
This position will allow the successful candidate the ability to work hybrid schedule with one day a week onsite and requires face-to-face visits when needed. This position will require regular visits with members in Adult Care Homes and with members living in the community, resulting in significant travel. If member facing visits occur during the week, office days are not required; otherwise, 1 office day/week is required.
Responsibilities & Duties
Provide Care Team Support
Support members transitioning from institutional care settings to community-based care.
Provide subject matter expertise, within scope of license, regarding member’s physical health to support the development and delivery of a whole person approach to Care Management
Work collaboratively with other Alliance staff, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities
Complete Assessments and Planning
Utilize person-centered planning, motivational interviewing, and assessments to gather information
Perform individual assessments/screenings for members that are medically fragile or have significant health conditions, have a mental health condition, substance use condition, or co-occurring intellectual or developmental disability.
In the Transition and Housing setting, staff will also assess and record member’s activities and progress.
Provide education and supports to members and/or legal guardians regarding self-care strategies, their rights and responsibilities, available treatment options, provider network availability and payor requirements that may impact service access or maintenance
Educate team members about impact of member’s health conditions on service engagement, clinical outcomes, and prognosis for change
Actively collaborate with member and care team members to ensure care plan accurately reflects the individual’s clinical needs and desired life goals
Update Assessments and plans of care as needed
Provide education about advanced directives, preferred natural support and physical health contacts whom the member identifies, and preferred crisis facilities
Provide medication reconciliation and education
Develop and update plans of care based off the needs identified in the assessments and complete the interventions identified as needed
Review member’s medical history and identify specific goals and types of activities that will be used to help member work to help work towards those specific goals
Proactively works with the member’s multidisciplinary care team to identify gaps in services and intervenes to ensure that the member is receiving the appropriate level of care
Complex Care Management OT staff may evaluate a member’s home and based on member’s needs, may identify needed improvements and/or special durable medical equipment and instruct member’s on how to use this equipment
Monitoring/Coordination
The CCM team will continue to be involved with the member for 90 days after the move to provide additional support and recommendations that may be needed to reduce crisis service/inpatient utilization and retain housing
Appropriately escalate high risk/high visibility and/or complex barriers/needs members who may have difficulty transitioning out of the facility in a timely manner to supervisors. High risk can involve Health and Safety of a member, staff, or organizational risk
Review cases with clinical complexity with direct supervisor, peer clinical review cohort, and utilization management care managers and medical management leadership as needed
Obtain information releases that will improve care management activities on behalf of the member
Reports care quality concerns to Quality Management as needed
Documentation
Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency, and Medicaid requirements
Follow administrative procedures and effectively manages caseload
Data
Review, validate and interpret risk stratification data and population health groups and recommend changes or adjustments to care management approach as needed
Utilize data to analyze needs of the members we serve, guide staff training development, identify resource needs and consistency of workflow implementation across disciplines
Travel
Travel to meet with members, providers, stakeholders, attend court hearings etc. is required
Minimum Requirements
Education & Experience
Graduation from a school of nursing and two years of full-time experience with the population served and active NC or Compact Registered Nurse License
Preferred Experience
Home & Community based service
Required License
Active, valid NC RN or Compact Registered Nurse License
Knowledge, Skills, & Abilities
Demonstrated knowledge of the assessment and treatment of mental health, substance abuse, intellectual and developmental disabilities,
Knowledge of legal, waiver, accreditation standards and program practices/requirements.
Knowledge of the Alliance Health service benefit plans and network providers.
Person Centered Thinking/planning
The employee must be detail oriented,
Ability to independently organize multiple tasks, priorities, and to effectively manage an assigned caseload under pressure of deadlines.
Exceptional interpersonal skills, highly effective communication ability,
Ability to make prompt independent decisions based upon relevant facts and established processes.
Problem solving, negotiation and conflict resolution skills
Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required.
Salary Range
$66,240 - $86,112/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
