The IDD Community Integration CM position provides a critical support to Alliance members with I/DD to successfully integrated from an institutional setting into independent community living settings of their choice. Responsibilities include building relationships and rapport with members and providers through in reach activities, with ongoing support transitioning into the community, and care management once in the community. Additional diversion planning and coordination is provided to members for their success in remaining in a community setting. This role is hybrid, requiring facility visits and home visits to meet member needs.
This position is primarily a remote role however there will be times where you will have to go into the field to do on site client visits or attend scheduled Alliance meetings.
Responsibilities & Duties-
Assessment & Monitoring
Document member and/or legally responsible person (LRP) consent to participate in the transition process and care management efforts
Within defined timelines, complete assessment of the member preferences and needs related to integrated community living through active listening, meaningful conversation, motivational interviewing, and the use of open-ended questions
Assess the whole person including physical, psychological, social, environmental, and spiritual needs
With appropriate consent, as applicable, collaborate with formal and informal caregivers or support network, providers, and others in the member’s interdisciplinary healthcare team to inform the assessment
Document the assessment findings, including not limited to, the member’s support systems (professional and informal), primary concerns, strengths, priorities, care need gaps, social needs, goals, etc.
Document member and/or LRP agreement regarding the identified care needs, opportunities, and goals for intervention identified through the assessment process
During member engagements and through available data related to resource utilization and quality metrics, monitor the member’s condition and response to the care plan and interventions
Document ongoing collaboration and engagement with the member, LRP, and others involved in the member’s care and support to reflect the member’s response to interventions and the care plan
Document new findings, barriers to care and services, and/or continued effectiveness of the current care plan, with notation of member’s understanding of and agreement with the assessment
Through ongoing, routine and ad hoc follow-up with the member and/or their support network, monitor progress towards goals and/or revise goals appropriately to be relevant and realistic with member input and agreement
Collaborate with member/LRP on progress towards goals met to determine appropriate time to end current episode of care management once transitioned into a community living setting of their choice
Care Planning
Based on assessment and member identified priorities, develop a member centric and agreed upon care plan in collaboration with appropriate and applicable formal and informal caregivers or support network, providers, and others in the member’s interdisciplinary healthcare team
Use of a member-centric, collaborative partnership approach that is responsive to the individual member’s culture, preferences, needs, and values
Develop care plan with a comprehensive, holistic, and compassionate approach to care delivery that integrates a member’s medical, behavioral, social, psychological, functional, and other needs
Consideration for the member’s care needs, barriers, and opportunities in development of the care plan
In collaboration with the member and their support network (formal and informal) include prioritized goals and outcomes to be achieved with associated interventions or actions needed to reach the goals
Include appropriate, relevant, and realistic goals to align with member needs and priorities
With reassessment, new findings, or member request, make any revisions or modifications needed to the care plan goals or interventions to influence positive member outcomes. Review with member for understanding of and agreement with revisions or updates to the care plan
In Reach, Transition, Care Coordination & Collaboration
Facilitating awareness of and connections with community supports and resources to support successful integration into and sustained success with community living
Referral to community & social support services, including providing referral, information, and assistance and follow-up in obtaining and maintaining community-based resources and social support services while providing comprehensive assistance securing key health-related services (e.g., filling out and submitting applications)
Foster safe and manageable navigation through the healthcare system to enhance the member’s timely access to services and achieve desired outcomes
Coordinate care, services, resources, and health education specified in the planned interventions
Ongoing communication and collaboration with the member’s formal and informal support systems (with appropriate consent), providers, and the interprofessional healthcare team
Provide evidence of facilitation, coordination, and collaboration to support transitional care management activities
Facilitate and coordinate with connection to community, local and state resources, primary care providers, members of the interdisciplinary healthcare team, and other relevant stakeholders
Document the collaborative and transparent communication with the healthcare team members
Advocacy
Document adherence to member privacy and confidentiality mandates during all aspects of facilitation, coordination, communication, and collaboration within and outside the member’s primary setting of care
Provide education and guidance on self-determination and self-management. Promoting informed and shared decision-making, autonomy, growth, and self-advocacy
Connect the member and/or their informal caregiver supports to education and training to help the member improve function, develop socialization and adaptive skills, and navigate the service system
Providing information to the member and their caregivers regarding their rights, protections, and responsibilities, including the right to change providers, the grievance and complaint resolution process, and fair hearing processes
Educate other healthcare and service providers in recognizing and respecting the member’s needs, strengths, and goals
Recognize, prevent, and eliminate disparities in accessing high quality care
Advocate for the least restrictive appropriate levels of care, timely and well-coordinated transitions, and allocations of resources to optimize outcomes
Identify system barriers to quality care, timely and appropriate services, in the least restrictive setting, escalating identified barriers to direct supervisor for additional support
Recognize potential rising risk or escalation and seek appropriate consultation with clinical operations and leadership such as, not limited to, medical directors, registered nurses, pharmacy, legal, compliance, organizational senior leadership, etc.
Actively participate in interdisciplinary care team rounds, peer conferences, ad hoc staffing, high-risk member committee, and other consultations as appropriate to the member’s needs and circumstances
Health Promotion
Assess readiness for change and provide the appropriate health education, aligned to the member’s health literacy, to foster a member’s engagement in their own health & wellbeing
Integrate behavioral change skills and standards throughout the care management process
Provide health education on acute and chronic conditions to prevent adverse outcomes or advancing conditions, maintain optimal health and/or recovery, and improve overall health and quality of life
Assess exposure to environmental impacts on health, provide education, and connection to resources to mitigate or reduce environmental barriers impacting poor health outcomes
Monitor for gaps in care, educate member on the importance of health promotion, early detection and screening, health maintenance and chronic condition management. With member, prioritize gaps in care to be addressed
Ensure member is informed and support them in prioritizing their gaps in care. Coordinate follow-up on gaps in care, assessing for any barriers to follow-through. Identify resources to remove barriers, allowing for appropriate access to and follow-up with health promotion activities
Educate member on and motivate to participate in healthy activities such as, not limited to, healthy eating, exercise, tobacco/nicotine cessation, stress management, weight management, community engagement activities, etc.
Teach self-management skills and share self-help recovery resources. Work with members to develop SMART goals to support achievement of health promotion and care plan goals
Document member engagement in and participation with setting SMART goals. Monitor for and document progress with SMART goal, assisting member to revise goals to be relevant and realistic
Assess and document member response to and understanding of education provided
Professional Accountability
Conduct self in a professional manner to align with Alliance values
Document in accordance with documentation guidelines, demonstrating adherence to regulatory and organizational standards
Accountable to meet performance and productivity expectations and metrics
Timely routine/ongoing and ad hoc member outreach and engagement according to standards and to meet the member’s needs
Complete assessments and care planning within timelines and based on triggering events/change in circumstances
Complete appropriate professional development to obtain and/or maintain required licensure and/or certifications
Pursue professional knowledge, practice excellence, and maintain competence in case management and health and human service delivery standards and best practices
Maintain compliance with federal, state, and local rules and regulations and organizational, accreditation, and certification standards
Demonstrate knowledge, skills, and competency in applying case management standards of practice and relevant codes of ethics and professional conduct
Minimum Requirements-
Education & Experience
Required:
Must meet North Carolina’s definition of a Qualified Professional (QP) per 10A-NCAC 27G .0104
Master’s degree in a human service field with one (1) year post-graduate degree accumulated I/DD experience
OR
Bachelor’s degree in a human service or other related field with two (2) years post-graduate degree accumulated I/DD experience
OR
Bachelor’s degree in a non-human service or other related field with four (4) years post-graduate degree accumulated I/DD experience
At least one (1) year of experience in a healthcare setting with an integrated whole person care model (inclusive of both physical and behavioral health).
NADD- Specialist required within 12 months of hire.
Preferred:
Completion of Money Follows the Person Transitions Institute training.
Experience working with individuals with I/DD in a facility-based setting.
Certified Case Manager.
Knowledge, Skills, & Abilities-
Applied knowledge of community-based DSP training.
Practical communication skills such as active listening, meaningful conversation, motivational interviewing, and the use of open-ended questions.
Able to analyze assessment findings and determine care needs, barriers, or gaps in care.
Evidence of the use of problem-solving skills and techniques to reconcile potentially differing points of view.
Computer proficiency in Microsoft Word, Teams, and Outlook.
Ability to apply basic knowledge of Microsoft Excel.
Ability to utilize computer equipment and web-based software to conduct work.
Ability to interact with various office staff as needed to support necessary workflows.
Ability to interact with healthcare professionals, patients, their families and other supports.
Ability to communicate effectively to individuals and groups through spoken, written and electronic media.
Ability to attend to detail, effectively prioritize and execute tasks in a timely manner.
Ability to work independently without a high degree of supervision.
Knowledge of and demonstrated ability to apply behavioral change skills and standards.
Knowledge of HCBS benefits, services, and waivers
Compensation Range-
$28.12-$37.96 hourly
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
