Minimum Education / Experience
- A bachelor's degree from an accredited college or university in a field related to health, psychology, sociology, social work, nursing or another relevant human services area, or licensure as a registered nurse (RN).
Special Qualifications
Two (2) years of experience working directly with individuals with an I / DD and for care managers serving members with LTSS needs : Two (2) years of prior LTSS and / or HCBS coordination, care delivery monitoring, and care management experience, in addition to the required cited above. This experience may be concurrent with the two years of experience working directly with individuals.I. Responsibilities
A. Comprehensive Care Management Services
Ensures the provision of Person-Centered Planning for all service delivery.Conducts outreach and engagement activities to engage members in care management.Conducts comprehensive assessment and reassessments within the required timeframes for acuity level of member.Facilitates the completion of the care plan, as well as ISP for Innovation Waiver services for members receiving waiver services, inclusive of crisis and safety plan.Facilitates engagement of extended care team and providers in care plan development and implementation though regular communication, care follow up, and care conferences.Utilizes clinical consultants for expertise in planning, care plan reviews, medication reviews, transitional care support, and other activities as appropriate.Supervises Care Extenders and their assigned care management activities.B. Care Coordination & Health Promotion
Conducts and coordinates activities identified on care plan to support members' achievement of goals and objectives.Makes referrals to community resources for primary and specialty medical care, physical well-being, mental health.Provides service coordination to ensure members access primary and specialty care, mental health services, long-term support, and other services.Links members and coordinates referrals for physical health, behavioral health, and Social Determinants of Health (SDOH) needs. SDOH needs are related, but not limited to economic stability, education access and quality, health care access and quality, community connection and engagement, and safety in communities.Utilize NCCares360 for referrals and follow up, as appropriate to the referral situation.Educate members about mental or physical health, abuse, violence prevention, medication, and available community and social resources.Facilitate member access to resources and services to develop work skills and to participate in social, recreational, or therapeutic activities to enhance interpersonal skills and develop social relationships.Monitors members' health indicators relevant to their health and disability diagnoses and ensures appropriate health screenings on recommended schedule.Coordinates members' medication reviews and reconciliation.Coordinates Innovations Waiver services for members on waiver to ensure required assessment completion; ISP development, implementation, and monitoring; provider choice; and information-sharing on self-directed options.Assigns and manages Extender role for care coordination and health promotion activities.C. Transitional Care
Monitors notification of admissions and discharges of ER and hospitalizations.Facilitates proactive planning for transitional care support (pre-discharge).Conducts care conferences with extended care team and clinical consultants for transition planning, transitional services, and follow-up.Updates care plan within required timeframes following transitions.Ensures follow-up services within 24 hours of discharge of inpatient hospitalization or ER visit.Coordinates after care needs for transitions.Provides education and crisis planning for hospitalization and institutionalization diversion.Provides ongoing outreach to identify and support members' community living preferences.24 : 7 Call Crisis Response CoordinationIdentifies and provides crisis response as necessary, following agency policies related to crisis.Participates in post crisis team care conference for future preventative support.D. Individual & Family Support
Ensure care plans reflect members' strengths and preferences.Educate members and families on rights, health issues, advanced care directives, self-directed services, and other issues and options.Facilitate referrals to peer support and self-care resources.Communicate with members and family in preferred manner for method, language, literacy levels, cultural respect and sensitivity, and other needs.Assigns and manages the Care Extender's responsibilities for individual and family support.E. Referrals to Community and Social Supports
Establishes collaborative relationships community resources for member support.Links members and coordinates referrals for physical health, behavioral health, and Social Determinants of Health (SDOH) needs. SDOH needs are related, but not limited to economic stability, education access and quality, health care access and quality, community connection and engagement, and safety in communities.Utilize NCCares360 for referrals and follow up, as appropriate to the referral situation.Assigns and manages the Care Extender's responsibilities for community resources referral activities.F. Health Information Technology / Care Management Platform
Use care management platform to manage workflows, tasks, and activities.Ensure timely documentation of activities and member contacts.Review data to identify and determine appropriateness for services, which includes monitoring utilization, reporting, clinical measurement data and compliance issues.Maintain documentation within the care management platform and relevant health record systems.G. Other
Collaborates with Supervising Care Manager and quality management regarding Quality Improvement (QI) projects, and to monitor and report quality measures to Tailored Plan.Comply with all agency and care management service policy and procedures.Maintain training as required and requested.Complete all other relevant responsibilities as assigned by the supervisor.II. Recruitment Standards
Knowledge and experience with NC Medicaid and Innovation Waiver.Current theories, principles, and practices for services to children and adults with I / DD.Will be knowledgeable and adhere to the provision of Person-Centered Planning for all service delivery.Ability to work in a fast-paced environment with flexibility and adaptability.Ability to plan, supervise, review, and evaluate the work of staff.Demonstrated interpersonal skills with excellent listening, verbal, and written communication skills.Ability to establish and maintain effective, collaborative relationships with internal staff, external stakeholders, and members.Ability to exercise strict confidentiality and sound judgment with respect to sensitive member information, maintaining the integrity of member.Knowledge of principles and practices of effective supervision, evaluation, and training.Ability to analyze, evaluate and make sound decisions.Ability to prepare clear, accurate and effective reports and other written materials.Ability to interpret, explain and apply regulations, policies, and procedures.Demonstrated skill with using Electronic Health Record and care management platforms.Excellent skills and proficiency in Microsoft Word, Google Suite, Excel, and navigating internet.Must have a valid North Carolina driver's license and be insurable by the agency's insurance carrier.III. Physical Requirements
Activities : Sitting, walking, typing, talking, hearingActivity Level : ModerateVisual Acuity : Requires visual acuity to perform an activity such as : preparing and analyzing data and figures; transcribing; viewing a computer terminal; and / or extensive reading.Working Conditions : The worker is not substantially exposed to adverse environmental conditions when performing typical office or administrative work on-site.Physical requirement : Must be able to lift 40 pounds.Travel : 50% (variable to change). Reliable transportation is required.VI. Hours / Days of Work
8 : 00 a.m. to 5 : 00 p.m., Monday through Friday (Exempt). The weekly schedule must be flexible to meet the needs of the agency and families served. Full-time Regular position. Rotation in on-call coverage required.
VII. Supervisor : Supervising Care Manager
