Care Manager - LP; Western NC

Overview

Location:

Remote - must live in or near Alleghany, Ashe, Watauga, Caldwell, Alexander, Iredell, Yadkin, Surry, or Wilkes County, North Carolina. This position will serve Wilkes County members. Residency in North Carolina or within 40 miles of the NC border is required. Travel is required.

This is a mobile position with work performed in members’ home communities. The Care Manager - Licensed Professional (Care Manager - LP) provides proactive intervention and coordination of care to eligible Vaya Health members to ensure appropriate assessment and services. The role works with the member and care team to identify and alleviate inappropriate levels of care or care gaps through assessment, interdisciplinary care planning, linkage and coordination across MH, SUD, I/DD, TBI, physical health, pharmacy, LTSS, and unmet health-related resource networks.

The Care Manager - LP supports and may provide clinical transition planning and tracks individuals discharged from facilities to ensure follow-up and prevent readmission. The Care Manager - LP uses licensed clinical knowledge to assess needs, inform care planning, provide clinical consultation, and offer recommendations for appropriate care.

Education and experience requirements, licensure, and other requirements are described in detail below.

Essential duties include collaboration with the care team, compliance, documentation, and ongoing engagement with members and providers to promote integrated, whole-person care.

Note: This description reflects the responsibilities and requirements as provided and does not introduce new or unverified information.

• Utilization of and proficiency with Vaya's Care Management software platform/administrative health record (AHR).
• Outreach and engagement with members and care teams.
• Compliance with HIPAA requirements, including Authorization for Release of Information (ROI) practices.
• Perform Health Risk Assessments (HRA): a comprehensive bio-psycho-social assessment addressing social determinants of health, mental health history, physical health history, activities of daily living, access to resources, and other areas to ensure a whole-person approach to care.
• 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 and diversion from institutional placement.
• Engage with providers, members, and care teams to ensure appropriate care planning and service delivery.

This position requires NC residency as defined by the NC Department of Health and Human Services and in-person contacts with members and their care teams in the counties served.

Clinical Assessment, Care Planning, and Interdisciplinary Care Team

• Identify, assess, and plan patient-centered care for members.
• Link members to formal/informal services across health domains (medical, behavioral health, and home-based services).
• Meet with members to conduct HRAs and gather information on health, behavioral health, developmental, medical, and social needs.
• Administer screenings (PHQ-9, GAD, CRAFT, ACES, LOCUS/CALOCUS, and others) and use results to provide education, self-management strategies, and referrals.
• Transcribe and review current medications into the Care Management platform to create a multisource medication list shared with prescribers.
• Support the care team in developing person-centered Care Plans addressing mental health, substance use, medical, and social needs and goals; ensure plans meet requirements and reflect member needs.
• Engage the care team, identify barriers, and resolve service dissatisfaction; work with members to determine appropriate interventions and outcomes.
• Review clinical assessments and provide consultation to providers as needed; interpret assessments to inform care management activities.
• Coordinate with RN, pharmacists, and other care team members to ensure integrated care and support member/LRP choices for involvement.
• Facilitate care team meetings and monitor progress; share assessment information with the care team as appropriate.
• Develop and maintain crisis…