Tailored Care Management Extender

General Position Description:

The primary responsibilities of the Behavioral Health Care Manager Extender are to promote the whole person,

integrated care by planning, coordinating, tracking, closing gaps in care, and monitoring care to

individuals to achieve the key goals of the behavioral health-tailored plans.

Performance Expectations and Competencies

Care Management Services

• Actively engages with individuals receiving Care Management services through assessment, care coordination, health promotion, and comprehensive transitional care/follow-up.   Documentation of Care Management assessment, planning, and coordination of care with the care team communicating regularly with care team members, and participating in case conferences. 
• Provide or ensure services to include comprehensive Care Management, care coordination, health promotion, comprehensive transition care/follow-up, individual and family supports, and referrals to community and social support services.

Coordination of Referrals

• Makes appropriate referrals to community resources and empowers individuals to be responsible for their own healthcare and personal needs. Referrals will focus on behavioral health, physical 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.

Coordinate Care Transition

• Coordinates follow-up services for individuals with recent inpatient hospitalization or Emergency Department visits within 24 hours of discharge.
• Coordinates aftercare needs for transitions in care such as release from incarceration, change in housing, or other life transitions.

24:7 Call – Crisis Response Coordination

• Identifies and provides emergency crisis response as necessary and follows agency policies related to crisis. Participation in agency on-call structure may be required and in 24:7 crisis response for members
• Participates in post-crisis team debriefing and provides feedback on ways to prevent future crises for the person served.

Establish Relationships with the Integrated Care Team and Community Resources

• Communicates effectively with individuals receiving services, providers, and other natural support as needed. Provide education regarding services to all parties involved in the care and support of the individual.
• Establishes collaborative relationships with integrated care team members and community resources within the assigned geographical region to improve resource linkage.

Maintain Documentation

• Maintain medical record compliance/quality.
• Ensure timely documentation of Care Coordination activities as required by department policy and procedures.

Other

• Review data to identify and determine appropriateness for services, which includes monitoring utilization, reporting, clinical measurement data, and compliance issues.
• Demonstrate knowledge of and comply with all agency policies and procedures, as well as service definitions related to specific program areas.
• Maintain training as required and requested
• Participates in Quality Improvement (QI) projects, to improve service delivery, and costs of care, on an as-needed basis.
• Complete all other relevant responsibilities as assigned by the supervisor.

General Knowledge, Skill, and Competencies:

General Knowledge of the dynamics of MH/DD/SA behavioral health disorders (BHD) and their impact upon persons served and their families; the bio/psycho/social factors involved in (BHD);  up-to-date principles/techniques (evidence-based/best practices) of crisis response, prevention, and intervention application to individuals possessing (BHD); the community resources available to persons with (BHD), to include behavioral health, social service, community services, and self-help groups; knowledge of billing and service record documentation requirements (NC Division of MH/DD/SA ASAM/IPRS, DMA/Value Options, LME’s, and PCC policy/procedure.

General Skill in the application of needs assessment/prevention/intervention techniques that are considered evidence-based/best practices as defined by the NC Division of MH/DD/SA, and/or literature/research, and organizational policy/procedure; skill in the delivery of services; skill in establishing/maintaining effective therapeutic and professional relationships with persons served and/or their family members; behavioral health providers; and, skill in accurately documenting services provided and billed.

Preferred and Minimum Position Qualifications:

• ·         Minimum of a high school diploma or GED
• ·         Must possess and maintain a valid Certified Peer Support Support certification 

  Additional Job Requirements (Licenses, Certifications, Personal Vehicle, etc.):

• Must have reliable transportation, maintain a valid driver’s license, and maintain adequate automobile insurance.
• Must be able to travel, if needed
• Must have the ability to operate a telephone, fax machine, and computer hardware/software
• Must have the ability to effectively hear and communicate.
• Individuals in this position may be required to work weekends based on the needs of the agency and as specified by the TCM Supervisor
• Occasional lifting/moving of at least 25 pounds.