LOCATION: Remote - must live in or near Wilkes County, NC. Incombent in this is required to reside in North Carolina or within 40 miles of the North Carolina border. This position requires travel.

GENERAL STATEMENT OF JOB

The 1915(i) Waiver Care Coordinator ("Care Coordinator") 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. Care Coordinator is also responsible for providing care coordination activities and monitoring to individuals who have been deemed eligible for 1915i services by North Carolina Department of Health and Human Services (DHHS). Care Coordinator works with the member and care team to alleviate inappropriate levels of care or care gaps, coordinate multidisciplinary team care planning, linkage and/or coordination of services across the 1915i service array and other healthcare network(s) including 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. Care Coordinator support and may provide 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 Care Coordinator also works with other Vaya staff, members, relatives, caregivers/ natural supports, providers, and community stakeholders. As further described below, essential job functions of the Care Coordinator include, but may not be limited to:

• Utilization of and proficiency with Vaya's Care Management software platform/ administrative health record ("AHR")
• Outreach and engagement
• Compliance with HIPAA requirements, including Authorization for Release of Information ("ROI") practices
• Performing NC Medicaid 1915i Assessment tool to gather information on the member's relevant diagnosis, activities of daily living, instrumental activities of daily living, social and work-related needs, cognitive and behavioral needs, and services the member is interested in receiving
• Adherence to Medication List and Continuity of Care processes
• Participation in interdisciplinary care team meetings, comprehensive care planning, and ongoing care management
• Transitional Care Management
• Diversion from institutional placement

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

Assessment, Care Planning and Interdisciplinary Care Team :

• Ensures identification, assessment, and appropriate person-centered care planning for members.
• Meets with members to complete a standardized NC Medicaid 1915i Assessment
• Links members with appropriate and necessary formal/ informal services and supports across all health domains (i.e., medical, and behavioral health home)
• 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, including 1915(i) services to address mental health, substance use or I/DD, medical and social needs as well as personal goals
  • Ensure the Care Plan includes all elements required by NCDHHS
  • Use information collected in the assessment process to learn about member's needs and assist in care planning
  • Ensure members of the care team are involved in the assessment as indicated by the member/LRP and that other available clinical information is reviewed and incorporated into the assessment as necessary
  • Work with members to identify barriers and help resolve dissatisfaction with services or community-based interventions
• Reviews clinical assessments conducted by providers and partners with licensed staff for clinical consultation as needed to ensure all areas of the member's needs are addressed. Help members refine and formulate treatment goals, identifying interventions, measurements, and barriers to the goals
• Ensures 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 process
• Works in an integrated care team including, but not limited to, an RN (Registered Nurse) 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 reviewed
• Solicits input from the care team and monitors progress
• Ensures that the assessment, Care Plan, and other relevant information is provided to the care team
• Consults with care management licensed professionals, care management supervisors, and other colleagues as needed to support effective and appropriate member care/planning process

Support Monitoring/Coordination, Documentation and Fiscal Accountability :

• Serves as a collaborative partner in identifying system barriers through work with community stakeholders.
• 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 (Care Manager) and receiving support and feedback regarding CM interventions for clients' medical, behavioral health, intellectual /developmental disability, medication, and other needs.
• Works with 1915 (i) Care Coordination manager in participating in 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.
• Ensure that services are monitored (including direct observation of service delivery) in all settings at required frequency and for compliance with standards
• 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.
• Make announced/unannounced monitoring visits, including nights/weekends as applicable.
• Promote satisfaction through ongoing communication and timely follow-up on any concerns/issues
• Monitor services to ensure that they are delivered as outlined in individualized service plan and address any deviations in service
• 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. Alerts supervisor and other appropriate Vaya staff if there is a change in member Medicaid eligibility/status.
• 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 accurate/timely submission of Service Authorization Requests (SARS) for all Vaya funded services/supports
• Proactively monitors own documentation within the AHR to ensure completeness, accuracy and follow through on care management tasks.
• Works with 1915 (i) Care Coordination Manager to ensure 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.

Other duties as assigned .

KNOWLEDGE, SKILL & ABILITIES

• Ability to express ideas clearly/concisely and communicate in a highly effective manner
• Ability to drive and sit for extended periods of time (including in rural areas)
• Effective interpersonal skills and ability to represent Vaya in a professional manner
• Ability to initiate and build relationships with people in an open, friendly, and accepting manner
• Attention to detail and satisfactory organizational skills
• Ability to make prompt independent decisions based upon relevant facts.
• 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
• Thorough 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 research
• 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 (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)
• Job functions with higher consequences of error may be identified, and proficiency demonstrated and measured through job simulation exercises administered by the supervisor where a minimum threshold is required of the position.

QUALIFICATIONS & EDUCATION REQUIREMENTS

Bachelor's degree in a field related to health, psychology, sociology, social work, nursing or another relevant human services area is preferred. Required years of work experience (include any required experience in a specific industry or field of study):

• Serving members with BH conditions:
  1. Two (2) years of experience working directly with individuals with BH conditions
• Serving members or recipients with an I/DD or Traumatic Brain Injury (TBI)
  1. Two (2) years of experience working directly with individuals with I/DD or TBI
• Serving members with LTSS needs
  1. Minimum requirements defined above
  2. Two (2) years of prior Long-tern Services and Supports and/or Home Community Based Services coordination, care delivery monitoring and care management experience.
  3. 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 above

OR a combination of education and experience as follows:

A graduate of a college or university with a Bachelor's degree in a human services field and two years of full-time accumulated experience with population served

OR

A graduate of a college or university with a Bachelor's degree is in field other than Human Services and four years of full-time accumulated experience with population served

OR

A graduate of a college or university with a Bachelor's Degree in Nursing and licensed as RN, and four years of full-time accumulated experience with population served. Experience can be before or after obtaining RN licensure.

OR

Please note, if a graduate of a college or university with a Master's level degree in Human Services, although only one year is needed to reach QP status, the incumbent must still have at least two years of experience with the population served

*Must meet the criteria of being a North Carolina Qualified Professional with the population served in 10A NCAC 27G .0104

Licensure/Certification Required:

If Bachelor's degree in nursing and RN, incumbent must be licensed to practice in the State of North Carolina by the North Carolina Board of Nursing.

PHYSICAL REQUIREMENTS

• 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)

RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit

Vaya Health is an equal opportunity employer.