Idd Care Manager (Henderson County)

• CM Platform basics
• Outreach & Engagement
• Release of Information practices
• Health Risk Assessment
• Medication List and Continuity of Care process
• Care Planning
• Interdisciplinary Care Team and Ongoing Care Management

Assessment, Care Planning and Interdisciplinary Care Team:

• Ensure identification, assessment and appropriate Person Centered Care Planning for members identified as having Special Health Care Needs or as High Risk High Cost members (as supported by state funds) or other Care Management populations and link to appropriate formal and informal services and supports (i.e. medical and behavioral health home)
• Meet with members to conduct a comprehensive bio-psycho-social assessment in order to gather information on their overall health, including behavioral health, developmental, medical and social needs
  • Health Risk Assessment (HRA) is a comprehensive assessment addressing social determinants of health, mental health history and needs, physical health history and needs, I/DD, activities of daily living, access to resources, and other areas to ensure a whole person approach to care
• May administer the PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings within their scope based on member’s needs
  • Scores are calculated and reviewed allowing I/DD Care Manager to provide specific education and self-management strategies as well as linkage to appropriate therapeutic supports. The assessment process includes reviewing and transcribing member’s current medication and entering information into Vaya’s Care Management platform to trigger the continuity of care process which results in the creation of a multisource medication list that is shared back with prescribers to promote integrated care
• Use assessment to learn about member's needs to aide in care planning,
• Create a person-centered care plan for members to help define what is important to members for their health and prioritize goals that help them live the life they want in the community of their choice and ensure Care Plan includes specific services to address mental health, substance use or I/DD, medical and social needs as well as personal goals
  • Care Plans are created based on information collected in the assessment process
  • Ensure members of the care team are involved as indicated by the member/guardian(s) and that other available clinical information is reviewed and incorporated into the assessment as necessary
  • Work with members to mediate dissatisfaction within the community
• Assist members in refining and formulating treatment goals, identifying interventions, measurements and barriers to the goals
• Ensures that member/guardian(s) is/are informed of available services (i.e. Individual/Family Direction for Innovations participants), processes (e.g., requirements for specific service), etc.
• Provide information to member/guardian(s) regarding their choice in choosing service providers, ensuring objectivity in the process
• Work in an integrated care team including, but not limited to, an RN and pharmacist along with the member to address needs and goals in the most effective way ensuring that member/guardian(s) have the opportunity to decide who they want involved
• Coordinates and may facilitate Care Team meetings where member Care Plan is discussed and reviewed
• Solicit input from the care team and monitor progress
• Ensures that the assessment, care plan and other relevant information is provided to the care team as indicated in Vaya policy and necessary Care Plan elements are included
• Review assessments conducted by providers and consult with clinical staff as needed to ensure all areas of the member’s needs are addressed
• Update Care Plans and Care Management assessment at a minimum of annually or when there is a significant life change for the member
• Work in partnership with other Vaya departments to address identified needs
• Participate in multidisciplinary huddles including RN, Pharmacist, M.D. and case staffings to present case to address barriers, identify need for specialized services to meet member needs and receive support and feedback regarding interventions for medical, behavioral health, I/DD, medication, and other needs and provide support to other Care Managers
• Risk Management- Proactively ensures that individuals identified as a Special Needs enrollee that have treatment needs or require regular monitoring have a Behavioral Health Clinical Home and a Medical Home
• Create a Care Management Crisis Plan which is separate and complimentary to the behavioral health provider’s crisis plan
  • Collaborate with members to develop a Crisis Plan that is tailored to their needs and desires
  • Ensure the Crisis Plan includes problem definition, physical/cognitive limitations, health risks/concerns, medication alerts, baseline functioning, signs/symptoms of crisis (triggers), de-escalation techniques
  • Provide crisis intervention, coordination, and care management if needed while with members in the community
• Represent Vaya at designated community stakeholder, provider and NC Department of Health and Human Services related meetings
• Promote use of natural/community resources through the assessment/planning process

• Ensure quality care, health/safety of the individual, as well as the continued appropriateness of services
• Ensure that services are monitored (including direct observation of service delivery) in all settings at required frequency
• Make announced/unannounced monitoring visits, including nights/weekends as applicable.
• Monitor services for compliance with standards
• Promote problem-solving and goal-oriented partnership with member/guardian(s), providers, etc. and recognize and report critical incidents
• Promote satisfaction through ongoing communication and timely follow-up on any concerns/issues
• Educate members/families on methodology for budget development, total dollar value of the budget and mechanisms available to modify the individual budget.
• Monitor services to ensure that they are delivered as outlined in individualized service plan and address any deviations in service
• Ensure that service orders/doctor’s orders are obtained, as applicable
• Alert supervisor and other appropriate Vaya staff if there is a change in member Medicaid eligibility/status
• Promptly follow-up on issues
• Proactively responds to a member’s planned movement outside the Vaya’s geographic area to ensure changes in their Medicaid County of eligibility are addressed prior to any loss of service
• Maintain electronic health record compliance/quality according to Vaya policy
• Coordinate Medicaid deductibles, as applicable, with the individual/guardian and provider(s).
• Proactively monitor own documentation to ensure that issues/errors are resolved as quickly as possible
• Ensure accurate/timely submission of Service Authorization Requests (SARS) for all Vaya funded services/supports
• Ensure all clinical and non-clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency and Medicaid requirements
• Participate in and maintain Care Management and Vaya trainings and proficiencies

• Ability to express ideas clearly/concisely
• Ability to drive and sit for extended periods of time (including in rural areas)
• Represent Vaya in a professional manner
• An ability to initiate and build relationships with people in an open, friendly, and accepting manner
• Strong attention to detail and superior organizational skills
• Ability to understand the strategic direction and goals of the department and support appropriate processes to facilitate achievement of business objectives
• Well-developed capabilities in problem solving and conflict resolutions skills
• A result and success-oriented mentality, conveying a sense of urgency and driving issues to closure
• Comfort with adapting and adjusting to multiple demands, shifting priorities, ambiguity, and rapid change
• Proficiency in Microsoft Office and Vaya systems, to include Excel, data analysis, and secondary research
• Demonstrated knowledge of the assessment and treatment of developmental disabilities, without co-occurring mental illness
• Have highly effective communication
• Knowledge in Vaya Medicaid B and C Waivers, NC Innovations Waiver, and accreditations and apply this knowledge in problem-solving and responding to questions/inquiries
• Have a dynamic, proactive approach to assessment, screening, monitoring and coordination of care, to ensure quality supports and consistent adherence to waiver requirements
• This is a mobile position with work done in a variety of locations spending a considerable amount of time in the field
• Understand the following areas, in addition to other required trainings:
  • BH I/DD Tailored Plan eligibility and services
  • Whole-person health and unmet resource needs (Adverse Childhood Experiences, Trauma, cultural humility)

• Community integration (Independent living skills; transition and diversion, supportive housing, employment, etc)
• Components of Health Home Care Management (Health Home overview, working in a multidisciplinary care team, etc)
• Health promotion (Common physical comorbidities, self-management, use of IT, care planning, ongoing coordination)
• Other care management skills (Transitional care management, motivational interviewing, Person-centered needs assessment and care planning, etc)
• Serving members with I/DD or TBI (Understanding various I/DD and TBI diagnoses, HCBS, Accessing assistive technologies, etc)
• Serving children (Child and family centered teams, understanding of the “System of Care” approach)
• Serving pregnant and postpartum women with Substance Use Disorder (SUD) or with SUD history
• Serving members with LTSS needs (Coordinating with supported employment resources

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.
• Ability to drive and sit for extended periods of time (including in rural areas)