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MHSU Care Manager

Company: Vaya Health
Location: Hayesville
Posted on: November 27, 2022

Job Description:


LOCATION: Remote - Clay County, NC
GENERAL STATEMENT OF JOB:The Mental Health/Substance Use (MHSU) Care Manager, hereafter referred to as care manager, is responsible for providing proactive intervention and coordination of care to eligible members and recipients of Vaya's Health plan to ensure that these individuals receive appropriate assessment and services. This Care Manager does not provide Home and Community Based Services (HCBS) Waiver care coordination. The Care Manager 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. Care Managers support and may provide 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. This is a mobile position with work done in a variety of locations. The Care Manager may work with members in their home communities. The Care Managers also works with other Vaya staff, members and family members, providers as well as community stakeholders. Essential job functions of the 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
  • Transitional Care Management
  • Diversion *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: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 appropriate formal/ 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, 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 MH/SU 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, 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, referral 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
  • Conducts education and referral to prevention and population health management programs.
  • 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
  • Conducts Transitional Care Management responsibilities
  • Coordinates Diversion efforts for members at risk of requiring care in an institutional setting
  • Link members to necessary services and supports across all health domains.
    Collaboration, Coordination, Documentation:
  • 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 address identified needs within the catchment.
  • CM may participate in cross-functional clinical and non-clinical meetings and other projects to support the department and organization.
  • Participate in routine multidisciplinary huddles including RN, Pharmacist, M.D. to present complex clinical case presentation and needs, providing support to other CM's and receiving support and feedback regarding CM interventions for clients' medical, behavioral health, intellectual /developmental disability, medication, and other needs.
  • CM participates in other high risk multidisciplinary complex case staffing's as needed to include Vaya Medical Director, 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.
  • Ensure quality care, health/safety of the individual, as well as the continued appropriateness of services
  • 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 services and resources.
  • Verify member continuing eligibility for Medicaid
  • Promptly follow-up on issues
  • Proactively responds to an 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
  • Proactively monitor own documentation to ensure that issues/errors are resolved as quickly as possible
  • 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
    Other duties as assigned.

Keywords: Vaya Health, Knoxville , MHSU Care Manager, Executive , Hayesville, Tennessee

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