Mhsu Embedded Care Manager - Lp (Buncombe County)

Job Description: LOCATION: Remote – must live in or near Buncombe County, NC GENERAL STATEMENT OF JOB The MHSU Embedded Care Manager, LP is responsible for providing proactive intervention and coordination of care to eligible Vaya Health members and recipients (“members”) to ensure that these individuals receive appropriate assessment and services. The MHSU Embedded Care Manager, LP is a unique position within the MHSU Care Management Team who performs all standard MHSU Care Manager job functions, supports an assigned local DSS agency (through virtual or on-site embedding), provides consultation, education, focused communication, and system navigation for DSS social workers, and serves as the primary point of contact for supporting DSS emergency placement issues. The MHSU Embedded Care Manager, LP works with the member and care team to identify and alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, linkage and/or coordination of services needed by the member across the MH, SU, intellectual/ developmental disability (“I/DD”), traumatic brain injury (“TBI”) physical health, pharmacy, long-term services and supports (“LTSS”) and unmet health-related resource needs networks, with a focus on those members and families involved with DSS. MHSU Embeddded Care Manager, LP support and may provide clinical transition planning assistance to state and community hospitals and residential facilities and track individuals discharged from facility settings to ensure they follow up with aftercare services and receive needed assistance to prevent further hospitalization. This is a mobile position with work done in a variety of locations, including members’ home communities. The MHSU Embedded Care Manager, LP Manager also works with other Vaya staff, members, relatives, caregivers/ natural supports, providers, and community stakeholders. The MHSU Embedded Care Manager, LP Manager also utilizes licensed clinical knowledge and skills to assess needs, inform care planning development, provide clinical consultation, and offer recommendations for appropriate care. As further described below, essential job functions of the MHSU Embedded Care Manager, LP includes, but may not be limited to:Utilization of and proficiency with Vaya’s Care Management software platform/ administrative health record (“AHR”)Outreach and engagementCompliance with HIPAA requirements, including Authorization for Release of Information (“ROI”) practicesPerforming Health Risk Assessments (HRA): a comprehensive bio-psycho-social assessment addressing social determinants of health, mental health history and needs, physical health history and needs, activities of daily living, access to resources, and other areas to ensure a whole person approach to careAdherence to Medication List and Continuity of Care processesParticipation in interdisciplinary care team meetings, comprehensive care planning, and ongoing care managementTransitional Care ManagementDiversion from institutional placementConsultation with DSSEducation and System Navigation with DSS This position is required to meet NC Residency requirements as defined by the NC Department of Health and Human Services (“NCDHHS” or “Department”). ESSENTIAL JOB FUNCTIONS Clinical Assessment, Care Planning, and Interdisciplinary Care Team:Ensures identification, assessment and appropriate person-centered care planning for members. Links members with appropriate and necessary formal/ informal services and supports across all health domains (i.e., medical and behavioral health home)Meets with members to conduct the HRA and gather information on their overall health, including behavioral health, developmental, medical and social needs. Administers the PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings based on member’s needs. The MHSU Embedded Care Manager, LP uses these screenings 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, which triggers the creation of a multisource medication list that is shared back with prescribers to promote integrated care.Supports the care team in development of a person-centered care plan (“Care Plan”) 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.Ensure the Care Plan includes specific services to address mental health, substance use, medical and social needs as well as personal goalsEnsure the Care Plan includes all elements required by NCDHHSUse information collected in the assessment process to learn about member's needs and assist in care planningEnsure members of the care team are involved in the assessment as indicated by the member/LRP and uses clinical skills to evaluate and incorporate other available clinical information into the assessment as necessaryWork with members to identify barriers and help resolve dissatisfaction with services or community-based interventionsUses clinical skills and expertise to review clinical assessments conducted by providers to ensure all areas of the member’s needs are addressed. MHSU Embedded Care Manager, LP reviews for clinical accuracy and may provide consultation and technical support to providers as needed based on reviews.Interprets and analyzes clinical assessments to draw clinical conclusions to support care management activities.Engages with provider clinical staff to determine clinical appropriateness and course of action when assessments present a wide array of treatment options and members present with complex needs.Helps members refine and formulate treatment goals, identifying interventions, measurements and barriers to the goalsEnsures that member/legally responsible person (“LRP”) is/are informed of available services, referral processes (e.g., requirements for specific service), etc.Provides information to member/LRP regarding their choice of service providers, ensuring objectivity in the processWorks 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/LRP have the opportunity to decide who they want involved Supports and may facilitate care team meetings where member Care Plan is discussed and reviewedSolicits input from the care team and monitor progressEnsures that the assessment, Care Plan, and other relevant information is provided to the care team Reviews assessments conducted by providers and consult with clinical staff as needed to ensure all areas of the member’s needs are addressedProvide clinical assessment in situations where the member’s lack of clinical home or available network provider creates significant risk to member well-being (e.g., need for time sensitive placement/ discharge from inpatient setting)Updates Care Plans and Care Management assessment at a minimum of annually or when there is a significant life change for the memberSupports and assists with education and referral to prevention and population health management programs.Works with the member/LRP and care team to ensure the development of a Care Management Crisis Plan for the member that is tailored to their needs and desires, which is separate and complementary to the behavioral health provider’s crisis planEnsures the crisis plan includes problem definition, physical/cognitive limitations, health risks/concerns, medication alerts, baseline functioning, signs/symptoms of crisis (triggers), de-escalation techniques. Provides crisis intervention, coordination, and care management if needed while with members in the community.Supports Transitional Care Management responsibilities for members transitioning between levels of careCoordinates Diversion efforts for members at risk of requiring care in an institutional settingConsults with care management licensed professionals, care management supervisors, and other colleagues as needed to support effective and appropriate member care. Collaboration, Coordination, Documentation:Utilizes advanced knowledge in their work which requires use of their advanced degree and licensure to be able to participate and initiate independent decisions with matters of significance and drive positive clinical outcomes for Vaya members.Coordinate and facilitate shared case staffing with DSS social workers, behavioral health providers, and Vaya care management to proactively plan for and communicate care needs.Provide clinical and administrative consultation for DSS social workers.Provide system navigation for DSS social workers to understand and work within the behavioral health system. Participate in DSS facilitated staffing to provide clinical consultation and support.Executes independent discretion and engages in business decisions for the Vaya Care Management Department that supports initiatives to promote Vaya’s integrated, whole-person care model for members.Serves as a collaborative partner in identifying system barriers through work with community stakeholders. Manages and facilitates Child/Adult High-Risk Team meetings in collaboration with DSS, DJJ, CCNC, school systems, and other community stakeholders as appropriate. Works in partnership with other Vaya departments to identify and address gaps in services/ access to care within Vaya’s catchment.Participates in cross-functional clinical and non-clinical meetings and other projects as needed/ requested to support the department and organization.Participates in routine multidisciplinary huddles including RN, Pharmacist, M.D. to present complex clinical case presentation and needs, providing support to other CMs and receiving support and feedback regarding CM interventions for clients’ medical, behavioral health, intellectual /developmental disability, medication, and other needs.Participates in other high risk multidisciplinary complex case staffing as needed to include Vaya CMO/ Deputy CMO, Utilization Management, Provider Network, and Care Management leadership to address barriers, identify need for specialized services to meet client needs within or outside the current behavioral health system.Monitors provision of services to informally measure quality of care delivered by providers and identify potential non-compliance with standards.Ensures the health and safety of members receiving care management, recognize and report critical incidents, and escalate concerns about health and safety to care management leadership as needed.Supports problem-solving and goal-oriented partnership with member/LRP, providers, and other stakeholders.Promotes member satisfaction through ongoing communication and timely follow-up on any concerns/issues.Supports and assists members/families on services and resources by using educational opportunities to present information.Verifies member’s continuing eligibility for Medicaid, and proactively responds to a member’s planned movement outside Vaya’s catchment area to ensure changes in their Medicaid County of eligibility are addressed prior to any loss of service.Proactively and timely creates and monitors documentation within the AHR to ensure completeness, accuracy and follow through on care management tasks.Maintains electronic AHR compliance and quality according to Vaya policy.Ensures all clinical and non-clinical documentation (e.g. goals, plans, progress notes, etc.) meet all applicable federal, state, and Vaya requirements, including requirements within Vaya’s contracts with NCDHHS.Participates in all required Vaya/ Care Management trainings and maintains all required training proficiencies.Participates in Vaya committees, workgroups, and other efforts that require clinical knowledge, as requested, and identified. Other duties as assigned. KNOWLEDGE, SKILL & ABILITIES:Ability to express ideas clearly/concisely and communicate in a highly effective mannerAbility to drive and sit for extended periods of time (including in rural areas)Exceptional interpersonal skills and ability to represent Vaya in a professional mannerAbility to initiate and build relationships with people in an open, friendly, and accepting mannerStrong attention to detail and superior organizational skillsAbility to make prompt independent decisions based upon relevant facts.Well-developed capabilities in problem solving, negotiation, arbitration, and conflict resolution, including a high level of diplomacy and discretion to effectively negotiate and resolve issues with minimal assistance.A result and success-oriented mentality, conveying a sense of urgency and driving issues to closureComfort with adapting and adjusting to multiple demands, shifting priorities, ambiguity, and rapid changeThorough knowledge of standard office practices, procedures, equipment, and techniques and intermediate to advanced proficiency in Microsoft office products (Word, Excel, Power Point, Outlook, Teams, etc.), and Vaya systems, to include the care management platform, data analysis, and secondary researchMust be highly skilled at shifting between macro and micro level planning, maintaining both the big picture, and seeing that the details are covered.Ability to use higher-level clinical training and licensure to perform clinical assessments, drive positive outcomes for members, support care management colleagues, and offer clinical assistance to providers.Highly skilled at performing clinical assessments of members and identifying member needs.Extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) within their scope and have considerable knowledge of the MH/SU/IDD/TBI service array provided through the network of Vaya providers. Experience and knowledge of the NC Medicaid program, NC Medicaid Transformation, Tailored Plans, state-funded services, and accreditation requirements are preferred.Ability to complete and maintain all trainings and proficiencies required by Vaya, however delivered, including but not limited to the following:BH I/DD Tailored Plan eligibility and services Whole-person health and unmet resource needs (ACEs, trauma-informed care, 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-c