***This is a provisional appointment meaning it is expected to have an end date within the next 12 to 18 months.***
This is a full-time remote opportunity. There is no expectation of being in the office routinely, however, the selected candidate must reside in North Carolina and be willing to travel throughout the Mecklenburg and surrounding counties to serve members as needed. Also must be available to travel to the Alliance office as needed for meetings.
The Department of Adult Correction (DAC) Liaison Transition Coordinator provides Liaison Transitional Care Management and Physical Health Consultation for members with physical and/or behavioral health needs in Justice System settings. The DAC Liaison Transition Coordinator will support individuals with serious mental illness (SMI) who are being released from a DAC facility. Individuals with serious mental illness (SMI) who are being released from a Department of Adult Correction (DAC) facility will be prioritized for re-entry coordination.
Responsibilities & Duties
Provide Care Team Support
Support members transitioning from Inpatient settings to the appropriate lower or lateral level of care.
Provide subject matter expertise, within scope, regarding member’s physical and/or behavioral 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.
Manage Core Re-Entry Transitional Care Coordinator Functions
Responsible for the care coordination and management, as required, for those on the SMI Reentry Prioritization List.
Utilize person-centered planning, motivational interviewing, and assessments to gather information.
Ensure communication between all parties, including DAC and related divisions (health service, re-entry, community supervision) and community behavioral and physical health providers.
Follow member for 90 days or until the individual qualifies for tailored care management (TCM) or other equivalent service, such as Assertive Community Treatment (ACT). This is subject to a further 90-day period as required.
Ensure referrals are made to all necessary services and supports including medication management, housing supports, other social determinants of health resources, behavioral and physical health care, and benefits coordination.
Participate in virtual and/or in person multisector meetings to facilitate the coordination and success of this initiative. These meetings will include DAC and DHHS representatives.
Ensure the timely completion of the initial care management comprehensive assessment and care plan prior to release from a DAC facility.
Ensure timely completion of the 90-day transition plan.
Coordinate and participate in care team meetings before and after release from a DAC facility Coordinate with the DAC assigned Re-entry Social Worker on transition from the DAC facility into community services for behavioral and physical healthcare.
Link to support systems in their community including housing and other social determinants of health resources.
Establish or reactivate health insurance benefits, as eligible, including all eligible public benefits such as Medicaid.
Ensure continuity of care from DAC post release based on all available information supplied by DAC and any post release assessments.
Coordinate with assigned community supervision officer, DAC/DHHS representatives and any relevant providers as applicable to the needs of the recipient.
Facilitate clinical warm handoffs to TCM Care Management, as applicable.
Assist the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence.
Develop an appropriate post-discharge plan before and after release, in consultation with the member, facility staff and the member’s care team, that outlines how the member will maintain or access needed services and supports, and transition to the new care setting.
Guide and facilitate arrangements for and scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven calendar days, unless required within a shorter time frame.
Collaborate with Physical Health for questions related to member’s Physical Health (i.e., CHF, Diabetes).
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 or ensure individual and family supports, including health promotion; addressing social determinants of health transitional care management.
Referral to TCL resources (diversion, in-reach; transition) as indicated. If a DAC referred individual is released before the plan is in place, then the plan must be completed no more than five (5) business days after the release from the DAC facility.
For the first 90 days, ensure at least four contacts with each recipient per month, including at least one in-person contact with the recipient. After the initial 90 days at least one contact per month with additional contacts tailored to the needs of the individual.
Consult with pharmacy or Physical Health consultant for medication reconciliation and education.
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.
Monitoring/Coordination Functions
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 and follow escalation protocols to ensure timely engagement from members or our Medical Team and Provider Networks.
Obtain information releases that will improve care management activities on behalf of the member.
Reports care quality concerns to Quality Management as needed.
Frequent Travel required for face to face engagement.
Management of Documentation
Ensure all clinical documentation (e.g., goals, plans, progress notes, etc.) meet state, agency, and Medicaid requirements.
Ensure accuracy and quality of Warm Hand Off summaries.
Follow administrative procedures and effectively manages caseload.
Collection and Analysis of 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.
Minimum Requirements
Education & Experience
Required:
Graduation from an accredited school of Nursing and three (3) years of full-time, post degree experience providing care management, case management, care coordination, discharge planning, or utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active RN license in North Carolina.
Or
Master’s degree from an accredited college or university in Human Services or related field and at least two (2) years of full-time, post graduate degree experience providing care management, case management, care coordination, discharge planning, or utilization management to members with Behavioral Health and Physical Health conditions in a behavioral health, medical, or managed care setting. Must have a valid, active clinical license (LCSW, LMFT, LCAS, LCMHC, LPA) in North Carolina.
Must reside in NC
Must have ability to travel as needed
Preferred:
NACCM, NADD-Specialist, Health Education Specialist, and/or CBIS certification preferred.
Knowledge, Skills, & Abilities
A 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.
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,
Extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version)
Considerable knowledge of the MHSU/IDD service array provided through the network of the LME/MCO’s Providers
Knowledge of LME/MCO’s implementation of the 1915(b/c) waivers and accreditation
Highly skilled at assuring that both long and short-range goals and needs of the individual are addressed and updated, while assuring through monitoring activities that service implementation occurs appropriately
Excellent computer skills including proficiency in Microsoft Office products (Word, Excel, Outlook, and PowerPoint)
Excellent problem solving, negotiation, arbitration, and conflict resolution skills
Detail-oriented, able to organize multiple tasks and priorities and effectively manage projects from start to finish
Ability to make prompt independent decisions based upon relevant facts, to establish rapport and maintain effective working relationships
Ability to change the focus of his/her activities to meet changing priorities
A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance
Salary Range
$66,240-$84,456.00/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
