Acute Transitional Care Manager; Henderson County, NC

LOCATION: Must live in or near Henderson County, NC. This position

Miami will be on-site at Pardee Hospital. The person in this position is required to maintain residency in North Carolina or within 40 miles of the NC border.

The Acute Transitional Care Manager (ATCM) is responsible for proactive intervention and coordination of care to members and recipients of Vaya’s Health plan who are receiving care in an inpatient community hospital or Emergency Department in some instances who require complex care planning to alleviate inappropriate levels of care or care gaps through 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 within the Acute Transitional CM professional scope.

The ATCM is responsible for knowing and implementing organizational policies, Division and departmental specific guidelines.

Activities may include but not limited to the following:

• In cooperation with community hospital discharge planning teams, participate in developing transition plans, educating staff and members regarding network services and supports with consideration of medical necessity, funding eligibility and appropriateness of recommendations relative to person centered, recovery principles and known best/appropriate practice.
• Develop, coordinate and link emergency discharge services (up to and including residential placement based on medical necessity, funding and service definitions or EPSDT for children/youth) for members who are inappropriately discharged from residential facilities (child or adult); coordination with Vaya’s Fast Track process; notifying Vaya Health Network of provider contractual concerns or through established process if quality of care or health and safety concerns;
• Notification and update of assigned community‑based Care Manager (CM) and care team if member is currently assigned.
• Coordination and consultation with Vaya RN CM for transition management support.
• Transition to community‑based CM post discharge.
• Participate in theокой development and implementation of best practice complex care strategies as identified by Vaya Health.
• Provide proactive and clear supervision supported by data to ensure supervisors and teams are meeting departmental and organizational benchmarks; and
• Collaborate with key stakeholders, network providers and non‑network providers with particular attention to crisis, inpatient, 3‑way bed contracts, NC START, etc.
• Engage and develop collaborative relationships with members using our Transitional Care Management and Tailored Care Management staff‑such as our Care Managers and Peer Support Specialists‑that use motivational interviewing techniques to understand the root causes that lead to exacerbation of symptoms and the use of emergency services or inpatient admissions.
• Address Unmet Health‑Related Resource Needs that may be barriers to care or impacting the health of members.
• Utilize ADT feeds and alerts to ensure prompt, efficient coordination and support.

This position works with staff, community partners and members in Vaya Health catchment.

Conduct or ensure all elements of transitional care management are implemented for members during inpatient stay to include, but are not limited to the following:

• Proactively ensures that members assigned to Vaya CM have a CM assigned to manage the transition
• Links members, at a minimum, to primary care and behavioral health care.
• Ensures that the care plan includes a transition plan and ensure it is developed by care team or, if necessary, by the ATCM to meet needs and to access care for the individual.
• Convenes key providers and others to address needs of the individual, ideally in person or telephonically while member is still in facility.
• Visit the member during their stay in hospital and be, or be sure a member of the care team, is present on the day of discharge.
• Identifies gaps inviendo services and supports, intervenes to ensure that the member receives and can access appropriate care.
• Measures…