MHSU DSS Embedded Care Manager - TP
Company: Vaya Health
Posted on: November 25, 2022
LOCATION: Remote - Graham County, NC
GENERAL STATEMENT OF JOB:The MHSU Care Manager (CM)- DSS, hereafter
referred to as DSS CM, is a unique position within the Mental
Health/Substance Use (MHSU) Care Management Team who is co-located
at our local Department of Social Services (DSS). This positions is
responsible for all the MHSU Care Manager aspects as well as
consultation, education, focused communication, and system
navigation for DSS social workers. Provides proactive intervention
and coordination of care to eligible members identified as Special
Health Care Needs, Complex Care Management or High-Risk High Cost
populations to ensure that these individuals receive appropriate
assessment and services, with a focus on those members and families
involved with DSS. Works with the member and care team to alleviate
inappropriate levels of care or care gaps through assessment,
multidisciplinary team care planning, linkage and/or coordination
of services across the MH/SU/IDD and other healthcare network(s)
with existing or new care team members. Supports clinical
transition planning assistance to local hospitals and tracks
individuals discharged from state and community hospitals to ensure
they follow up with aftercare services and receive needed
assistance to prevent further hospitalization. Point of contact for
supporting DSS emergency placement issues. This is a mobile
position with work done in a variety of locations but primarily
co-located with the local Department of Social Services and in
memebers home communities. Essential job functions of the MHSU Care
Managers include, but may not be limited to:
- 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
- Consultation with DSS
- Education and System Navigation with DSS *Must reside in North
CarolinaNote: This position requires access to and use of
confidential healthcare information or protected health information
(PHI) as described in laws addressing patient confidentiality,
including, but not limited to, the federal HIPAA law, the
Confidentiality of Alcohol and Substance Abuse Patient Records law,
42 CFR Part 2, and various state laws. As such, the individual
filling this position shall be required to be trained regarding
such laws and shall be required to observe those laws in his/her
capacity as an employee of Vaya Health. The individual filling this
position shall also sign a confidentiality statement as an employee
of Vaya Health.
ESSENTIAL JOB FUNCTIONS: Consultation, Collaboration, System
- Coordinate and facilitate a shared case staffing with DSS
social workers, behavioral health providers and Vaya care
management in order to proactively plan for and communicate care
- Provide clinical and administrative consultation for DSS social
- Provide system navigation for DSS social workers to understand
and work within the behavioral health system. Participate in DSS
facilitied staffings to provide consultation and support.
- Serve as a collaborative partner in identifying system barriers
through work with community stakeholders.
- Manage and facilitate Child/Adult Team meetings in
collaboration with DSS, DJJ, CCNC, school systems, and other
community stakeholders as appropriate.
- Partner with other Vaya departments to address identified needs
within the catchment.
- DSS CM may participate in cross-functional clinical and
non-clinical meetings and other projects to support the department
- Participate in routine multidisciplinary huddles including RN,
Pharmacist, M.D. to present complex clinical case presentation and
needs, providing support to other CCM's and receiving support and
feedback regarding CM interventions for clients' medical,
behavioral health, intellectual /developmental disability,
medication, and other needs.
- Participate in other high risk multidisciplinary complex case
staffing's as needed to include Vaya Chief Medical Officer, Deputy
Chief Medical Officer, 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.
- Meets 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
- Administer the PHQ-9, GAD, CRAFFT, ACES, LOCUS/ CALOCUS, and
other assessments based on member's clinical needs and scores are
calculated and reviewed allowing CM to provide specific education
and self-management strategies as well as linkage to appropriate
- Review and transcribe member's current medication and entering
into Vaya's Care Management platform to ensure the medication
aspects of the members health and care are addressed according to
- Ensure members of the care team are involved in the assessment
as indicated by the member and other available clinical information
is reviewed and incorporated into the assessment.
- Review clinical assessments conducted by providers to ensure
all areas of the member's needs are addressed.
Care Planning & Interdisciplinary Care Team:
- Create a person-centered care plan for members to help define
what is important to members for their health.
- Assist members in refining and formulating treatment goals,
identifying interventions, measurements, and barriers to the
- Partner with the integrated care team (i.e. RN and pharmacist)
along with the member to address needs and goals in the most
effective way and monitor progress.
- Ensure Care Plans include specific services to address mental
health, substance use or intellectual/developmental disability,
medical and social needs as well as personal goals.
- Ensure care plans are developed at least once a year or anytime
there is a significant life change.
- Ensure members/guardians have the opportunity to decide who
they want at the care team meeting and coordinates and may
facilitate the team meeting where member Care Plan is discussed and
- Ensure the assessment, care plan and other relevant information
is provided to the care team as indicated in Vaya policy.
Other duties as assigned.
QUALIFICATIONS & CREDENTIALING REQUIREMENTS: Bachelor's Degree in a
field related to health, psychology, sociology, social work,
nursing or another relevant human services area or licensure as an
RN* (see licensure section) and the following experience:
- Serving members with BH conditions:
- Two (2) years of experience working directly with individuals
with BH conditions
- Serving members or recipients with an I/DD or Traumatic Brain
- Two (2) years of experience working directly with individuals
with I/DD or TBI
- Serving members with LTSS needs
- Minimum requirements defined above
- Two (2) years of prior Long-tern Services and Supports and/or
Home Community Based Services coordination, care delivery
monitoring and care management experience.
- This experience may be concurrent with the two years of
experience working directly with individuals with BH conditions, an
I/DD, or a TBI, described aboveOR, a combination of education and
experience as follows:Meet North Carolina's Qualified Professional
Definition: graduate of a college or university with a bachelor's
degree in a field other than human services and has four years of
full-time, post-bachelor's degree accumulated MH/DD/SA experience
with the population served, or a substance abuse professional who
has four years of full-time, post-bachelor's degree accumulated
supervised experience in alcoholism and drug abuse counseling.
*Full-time Mental Health/Developmental Disabilities/Substance Abuse
Services experience required for credentialing as a Qualified
Professional may be obtained before or after obtaining the
- Close visual acuity to perform activities such as preparation
and analysis of documents; viewing a computer terminal; and
- 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)
KNOWLEDGE OF JOB:
- Familiar with Department of Social Services regulations and
- Participate in and maintain Care Management and Vaya trainings
and proficiencies as required.
- A high level of diplomacy and discretion to effectively
negotiate and resolve issues with minimal assistance.
- Exceptional interpersonal skills, highly effective
communication ability, and the propensity to make prompt
independent decisions based upon relevant facts.
- Problem solving, negotiation, arbitration and conflict
resolution skills are essential to balance the needs of both
internal and external customers.
- Highly skilled at shifting between macro and micro level
planning, maintaining both the big picture and seeing that the
details are covered.
- Extensive understanding of the Diagnostic and Statistical
Manual of Mental Disorders (current version)
- Knowledge of the MH/SU/DD service array provided through the
network of Vaya providers.
- Knowledge in Vaya Medicaid B and C waivers and accreditation is
- Detail oriented, able to organize multiple tasks and
priorities, and to effectively manage projects through
- Ability to change the focus to meet changing priorities.
- Exceptional communication skills, peer partnership, making
appropriate decisions in high stress situations, being polite,
respectful and assertive while maintaining positive
- Knowledge of standard office practices, procedures, equipment
and techniques and have intermediate to advanced proficiency in
Microsoft office products (Word, Excel, Power Point, Outlook,
- Understand the following areas, in addition to other required
- BH I/DD Tailored Plan eligibility and services
- Whole-person health and unmet resource needs (ACEs, Trauma,
- 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
- 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,
- Serving children (Child- and family-centered teams,
Understanding of the "System of Care" approach)
- Serving pregnant and postpartum women with SUD or with SUD
- Serving members with LTSS needs (Coordinating with supported
employment resourcesLICENSURE:*If RN, licensure as an North
Carolina RN (see education section)
LOCATION REQUIREMENT:In accordance with the BH and I/DD Tailored
Plan requirements mandated by the NC Department of Health and Human
Services, certain Vaya Health positions are required to be filled
by individuals who reside in North Carolina, meaning someone who
establishes a legal domicile in North Carolina and pays income tax
in North Carolina, or resides within 40 miles of the North Carolina
border. New hires from outside of North Carolina will have 60 days
from the date of hire to meet this requirement, if applicable to
the position.This position is required to reside in North Carolina
or within 40 miles of the North Carolina Boarder.
SALARY: Depending on qualifications & experience of candidate. This
position is exempt and is not eligible for overtime
DEADLINE FOR APPLICATION: Open until filled
APPLY: Vaya Health accepts online applications in our Career
Center, please visit http://www.vayahealth.com/careers-overview/
Vaya Health is an equal opportunity employer.
Keywords: Vaya Health, Knoxville , MHSU DSS Embedded Care Manager - TP, Executive , Robbinsville, Tennessee
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