CSFP Care Manager – $5,000 Hiring Bonus Position Available In Swain, North Carolina

Job Description:

Job Title:

CSFP Care Manager Job Code:

CSFP CM Department:

Tribal Option/ Primary Care Division:

Nursing/Tribal Option Salary Level:

Non-Exempt 12 Reports to:

CSFP Care Management Supervisor Last Revised:

August 2024 Primary Function The CFSP(Children and Families Specialty Program) aims to improvethe health and well-being of children, youth and families served by the childwelfare system. The CFSP design emphasizes a family-focus and seeks to:

• Improve members’ near
• and long-term physical and behavioralhealth outcomes.
• Increase timely access to physical health, behavioral health,pharmacy, LTSS and I/DD providers with experience serving children with highacuity needs, as well as unmet health-related resource needs.
• Strengthen and preserve families, prevent entry and re-entryinto foster care, and support reunification and other permanency plan options.
• Coordinate care and facilitate seamless transitions for memberswho experience changes in treatment settings, child welfare placements,transitions to adulthood, and/or loss of Medicaid eligibility.
• Improve coordination and collaboration with county DSSagencies, EBCI Family Safety Program, and more broadly, with CommunityCollaboratives
• a comprehensive network of community-based services andsupports leveraging a system of care approach to meet the needs of familieswho are involved with multiple child service agencies.
• Provide services that meet children’s behavioral health needsand prevent children from boarding in county DSS agency offices andEmergency Departments. For Members that have Tailored Care Plan eligibility, the incumbentis responsible for those aspects of care for that member. 2 Job Description
• Utilizes best practice models to identify, incorporate ordevelop best practices for panel management. Collaborates with other teams to share andestablish best practice for health promotion and disease preventionstrategies.
• Manages panel by addressing and resolving acute care needs andchronic care needs through a team based approach.
• Utilizes iCare to track, monitor, and assure the appropriatefollow-up of clients targeting specific indicators.
• Utilizes the care management platform for documentation of caremanagement functions such as a care needs screening, Comprehensive assessment,and care planning. Also utilizes the dashboards, within the care managementplatform for population health and related interventions and innovations
• Utilizes NC Health connects for information gathering and datacollections for management of care needs or gaps in care
• Coordinates and follows up on referrals to outside specialtyproviders, recent ED visits, and ICC visits. Emphasis is placed on ensuring treatmentnotes are available to the PCP timely.
• Participates in the continued development of the role of CaseManagement in the Patient Centered Medical Home (PCMH) and Advanced Medical Home(AMH).
• Promotes health care outcomes with currently accepted clinicalpractice guidelines.
• Provides patient education, advice and information on healthassessment, disease processes, medications, treatment plans and available communityresources.
• Assesses patient needs using established clinical guidelines,protocols, and pathways.
• Provides appropriate follow up as directed or per establishedguidelines.
• The incumbent will be evaluated annually on his/her ability toidentify, assess, analyze, and evaluate data and solve problems through the CIHPerformance Appraisal System.
• Collects data from relevant sources (patient, family, orcaregiver) regarding the biological, psychological, social and cultural factors that mightinfluence and impact the health status of the individual and utilizes this datain patient center care plan development.
• Collects data through observations of appearance and behavior,measurements of physical structure and physiological function, and otherinformation in an effort to place consultations and/or referrals to the correct internal andexternal resources (Nutrition, Tsali Manor, etc.).
• Interprets data and recognizes existing relationships betweendata collected and the client’s health status and treatment regimen and determines theclient’s need for immediate nursing interventions.
• Reviews the patient’s health records and health summary,interviewing patients and family members, documenting the chief complaints, medicalhistory, physical and clinical findings, identifying learning needs of the patientand family, and determining priority of care required. Assessment for healthprevention, health promotion, restorative, and health maintenance needs isemphasized. 3
• Will plan patient care according to individual assessed patientneeds and established hospital policies and procedures.
• Develops individualized plan of care with input from thepatient, patient’s family, care team members, and anyone else the patient requests to beincluded for those patients considered “high risk.”
• Initiates individualized care plan based on assessment of thepatient for specific illnesses, injuries, and diseases Social Determinants of Health(SDoH) and human behavior while adhering to appropriate standards of care.
• Develops expected patient outcomes that are observable andwithin an adequate period, and are congruent with the patient’s present and potentialphysical capabilities and behavioral patterns.
• Assumes coordination responsibility for transitionplanning.

o Use of ADT including high risk

ADT Alerts:

• Real time (within minutes/hours) response to notifications ofED visits.
• Same-day or next-day outreach for designated high-risk subsetsof the population; and
• Additional outreach within several days after the alert toaddress outpatient needs or prevent future problems for other patientswho have been discharged from a hospital or an ED (e.g., to assistwith scheduling appropriate follow-up visits or medication reconciliations post-discharge).
• May be required to change work schedule to assist in coveringfor periodic “late clinics.”
• Coordinates closely with each member’s primary care provider(PCP), and, as appropriate, care manager extenders, assigned County Child Welfareworker, EBCI Family Safety Program staff, CIHA Care Team, family membersand guardians to manage the member’s health care needs throughout theirtime enrolled in the CFSP.
• Directs the extender’s care management functions and ensurethat the extender supports allowable activities (e.g., coordinatingservices/appointments by arranging transportation, etc.).
• Conducts a care management comprehensive assessment for eachmember
• Develops a care plan (for members without I/DD and TBI needs)or an individual support plan (ISP) (for members with I/DD and TBI needs).

o The care plan/ISP will provide a blueprint for ongoing caremanagement and include the member’s health, social, emotional, educational andother service needs and relevant permanency planning information fromthe member’s assigned County Child Welfare worker or EBCI FamilySafety Program staff as applicable, among other elements. o For members receiving treatment in a congregate setting (e.g.,group home or PRTF), the member’s care plan/ISP will also identify theneeded 4 services, supports, and timeline to facilitate the member’stransition to a family-based placement, as clinically appropriate. o Include standard timelines that care managers must meet foradministering care management comprehensive assessments and developing each member’s care plan/ISP; the required timelines will differ formembers identified as high-risk compared to members not identified ashigh-risk. o Delivery of the care management comprehensive assessment and development of the care plan/ISP must be accelerated, as needed,to manage members’ urgent needs/crises.

• May be required to provide 24/7 support during emergencies orbehavioral health crises, including working with County Child Welfare workers (orEBCI Family Safety Program staff) to secure immediate treatment services, asneeded.
• Responsible for establishing a multidisciplinary care team foreach member.

o For children, this multidisciplinary care team might include butis not limited to the member, the member’s assigned care manager,parent(s), guardian(s), or custodian(s) (as appropriate), the County ChildWelfare worker, care manager extenders, and the member’s PCP. o For adults, the multidisciplinary team might include but is notlimited to the member’s assigned care manager, the County Child Welfareworker, care manager extenders, and the member’s PCP.

• Responsible for convening the care team on a regular basis (noless than twice per year, and more often, as appropriate) and will share the careplan/ISP with the member’s care team and other representatives, as appropriate, tosupport delivery of the member’s needed health and health-related services.
• Required to coordinate closely with each member’s assignedCounty Child Welfare worker o For CFSP members who are served by the EBCI Family SafetyProgram instead of NCDSS or county DSS agencies, the CFSP will be requiredto coordinate with EBCI Family Safety Program staff in place ofCounty Child Welfare workers.
• Meet and coordinate with County Child Welfare workers (or EBCIFamily Safety Program staff) to: o Share relevant health and health-related information, aspermitted, and coordinate strategies to address members’ health and social needsto support and promote family preservation, permanency planningand reunification, as applicable o Assist with scheduling NCDSS-required health assessments,gathering medical records, and developing a crisis plan.

Identify health andhealth related services that are necessary to support family preservationfor families receiving CPS In-Home Services and reunification orother permanency planning efforts for children in foster care and theirfamilies o Obtain consent for treatment of certain health care conditionsfrom a member’s parent(s), guardian(s), or custodian(s), unless thereare 5 restrictions regarding such communication (e.g., termination ofparental rights or court order restricting communication) in accordancewith applicable North Carolina state law.

• Provides transitional care management during care transitions(including assisting individuals with transitioning from congregate or other intensivetreatment settings to a foster care home or other community placement).

o notify the County Child Welfare worker or EBCI Family SupportSafety Program staff, as appropriate, and parents(s), guardians(s) and custodian(s), as appropriate, of a change in health plan and assistin selecting a new PCP, if necessary. o required to connect with the member before and after discharge,conduct discharge planning, facilitate clinical handoffs and arrange formedication reconciliation and management following discharge from a hospitalor institutional setting or following an emergency departmentvisit.

• Collaborate with County Child Welfare workers as needed in thedevelopment of the NCDSS-required transitional living plan and 90-day transitionplan. o identify key health-related resources and supports necessary toachieving the member’s health care goals o developing a Health Passport for each member as a supplement tothe 90day transition plan.
• The Health Passport is a document, available electronically andin paper formats, which will contain critical health care-related information, such as upcoming scheduled visits, prescribed medications and the member’s medical records.
• educate members about potential Medicaid and alternative insurance options available to them (e.g., Marketplace/Qualified Health Plan (QHP) coverage, applicable EBCI tribal programs/funding options, etc.) and assist them in signing up if desired, for former foster youth aging out of the Medicaid for Former Foster Care categorical Medicaid eligibility group
• transitioning all ongoing health care services and medications. The Health Passport for these members must also include a list of health care resources available to members regardless of insurance status.
• Responsible for ensuring members receive robust medicationreconciliation and management.

This will include, at minimum, medicationreconciliation and management following health care and other life transitions(including placement changes), assistance with refilling medications, and leveragingCFSP clinical staff (e.g., psychiatrist) to assess the clinical appropriateness ofmembers’ medication regimens.

• Responsible for implementing the Healthy Opportunities Pilot(HOP) program for its HOP-eligible members, 6
• May be subject to on-call and callback.
• Evaluates patient care provided.
• Directly observes and evaluates patient care.
• Revises nursing care and care plans to reflect changes in patientneeds.
• Documents nursing care and patient progress according to hospitalpolicy.
• Participates in ongoing nursing quality assurance program.
• May be necessary to work when Administrative leave is grantedif patient care would be compromised. Education, Licensure, Certification, and Experience
• A bachelor’s degree and Five years of experience providing caremanagement, case management, or care coordination to complex individuals withCSFP or foster care; or
• A master’s degree in a human services field and Three years ofexperience providing care management, case management, or care coordination tocomplex individuals with CSFP or foster care.
• If a RN, applicant must have an unrestricted valid RegisteredNurse license within the state of North Carolina or a state that is accepted asreciprocity.
• Current Basic Life Support (BLS) minimally required. Can beacquired through the facility within 6 months following appointment to position.
• Specific experience working with Native Americanspreferred.
• Applicant must have a valid North Carolina driver’slicense. Job Knowledge
• Knowledge and ability to independently plan, manage, andorganize work in order to meet priorities, accomplish work within established time framesand work in stressful situations.
• Knowledge of the occupational functions of multi-disciplinaryhealth care team.
• Knowledge of the culture and medical health profile of thepatient population.
• Knowledge and ability to teach and counsel patient/family onhealth maintenance and disease prevention.
• Knowledge of available health care programs and communityresources.
• Knowledge of problem oriented medical record methods.
• Knowledge of care management including screenings, assessments,development of care plans and knowledge of resources available to members atall levels including tribal, county, regional and state.

o In addition, have a working knowledge of the special needs ofmembers who fall into the category of being eligible for Tailored Carewhich includes those members with care needs related to a behavioralhealth condition (including both mental health and substance usedisorders), intellectual/developmental disability (I/DD), or traumatic braininjury (TBI).

• Knowledge is required of and to have expertise in the systemsand tools that are fundamental to the transition to adulthood, including independentliving skills 7 (e.g., accessing food and transportation), post-high schooleducation, housing and employment options, self-advocacy, health insurance coverageoptions after Medicaid eligibility ends and building natural supports.
• Knowledge of ISP/Care Plan development and implementation formembers of EBCI Tribal Option (TO) that are tailored plan eligible includingthe following: o Responsibility of the six core Health Home Services for thetailored plan
• Comprehensive care management
• Completion of care management comprehensive assessments and care plan/ISP
• Phone call or in-person meeting focused on chronic care management (e.g., management of multiple chronic conditions)
• Care coordination, including
• Working with the member on coordination across settings of care and services (e.g., appointment/wellness reminders and social services coordination/referrals)
• Assistance in scheduling and preparing members for appointments (e.g., phone call to provide a reminder and help arrange transportation)
• Health promotion, including
• Providing education on members’ chronic conditions
• Teaching self-management skills and sharing self-help recovery resources
• Providing education on common environmental risk factors including but not limited to the health effects of exposure to second
• and third-hand tobacco smoke and e-cigarette aerosols and liquids and their effects on family and children
• Comprehensive transitional care/follow-up, including
• Visiting the member during the member’s stay in the institution and be present on the day of discharge
• Reviewing the discharge plan with the member and facility staff
• Referring and assisting members in accessing needed social services and supports identified as part of the transitional care management process, including access to housing
• Developing a 90-day post-discharge transition plan prior to discharge from residential or inpatient settings, in consultation with the member, facility staff, and the member’s care team
• Individual & family support, including
• Providing education and guidance on self-advocacy to the member, family members, and support members 8
• Connecting the member and parents/other family members/caregivers to education and training to help the member improve function, develop socialization and adaptive skills, and navigate the service system
• Providing information to the member, family members, and support members about the member’s rights, protections, and responsibilities, including the right to change providers, the grievance and complaint resolution process, and fair hearing processes
• Referral to community & social support services, including
• Providing referral, information, and assistance and follow upin obtaining and maintaining community-based resources and social support services
• Providing comprehensive assistance securing key health relatedservices (e.g., filling out and submitting applications)
• Person Centered Thinking/planning
• Knowledge of using assessments to develop plans of care
• Knowledge of LOC process, SIS for IDD and FASN assessment forTBI
• Knowledge of Medicaid basic, enhanced MH/SUD, and waiverbenefits plans
• Knowledge of and skilled in the use of MotivationalInterviewing and techniques
• Strong interpersonal and written/verbal communicationskills
• Conflict management and resolution skills
• Proficient in Microsoft Office products (such as Word, Excel,Outlook, etc.)
• Ability to master care management platforms and review data fordecision making and person-centered planning
• High level of diplomacy and discretion is required toeffectively negotiate and resolve issues with minimal assistance.
• Ability to make prompt, independent decisions based uponrelevant facts
• Good organizational skills to prioritize duties and work withminimal levels of onsite supervision to consistently meet deadlines Complexity of Duties Complies also with federal, state, accrediting and localregulations.

These guidelines are not always specifically applicable to the individual patient orsituation and independent 9 judgment is required in selecting the most appropriate guideline,and applying the intent of the guideline to the specific situation at hand. Supervision Received The nurse independently plans, schedules, and provides nursing carein coordination with the medical care plan and attempts to solve problems only withinestablished procedures. This is done under the supervision of the CSFP Care ManagementSupervisor and Assistant Director of Care Management. The work is evaluated fortechnical soundness and adherence to professional standards. Responsibility for Accuracy The incumbent has a positive effect upon the recovery of thepatient and is responsible for following policies and procedures, which serve as hospitalguidelines and prevents errors from occurring. Errors can have a negative patient outcomesince the incumbent’s performance affects the health, recovery, and rehabilitation ofpatients, and the quality of care provided. Evaluations and observations are used to modify anddevelop clinically appropriate treatment plans. Work can be verified or checked by theimmediate supervisor, other health care providers or systems checks, butusually the responsibility for accuracy relies solely on the incumbent. Contacts with Others Contacts are with patients, families, hospital personnel, andcommunity agencies. Contacts with patients, families, and hospital personnel are toexchange, provide, and obtain information concerning the patient’s physical andpsychosocial health care problems, and needs. The nurse uses teaching and counseling methodsto influence and motivate patient and family behavior. Contacts with other healthcare or related disciplines within the hospital are for the purpose ofcollaboration and consultation. Tact, courtesy, and professional conduct are required to maintainpositive working relationships. Utmost sensitivity and confidentiality is requiredwhen dealing with patients and families. Confidential Data The incumbent has access to highly confidential patient medical andpersonal information. The Privacy Act of 1974 mandates that the incumbentshall maintain complete confidentiality of all administrative, medical, and allother pertinent information that comes to his/her attention or knowledge. The Actcarries both civil and criminal penalties for unlawful disclosure of records. Violationsof such confidentiality shall be cause for adverse action. Mental/ Visual/ Physical Work in the various services within the nursing department ismostly sedentary, yet requires walking, standing, bending, pushing, and lifting inhelping patients to and from beds, wheelchairs, and stretchers. These same activities arerequired in moving equipment and medical supplies. Will be subject to frequentinterruptions requiring varied responses, which can cause distractions therefore, theincumbent must possess the ability to differentiate and prioritize many tasks at once. 10 Work Environment Must be flexible in working hours. Work is performed in the clinicsetting, which is responsible for treating patients with a wide variety of medicalproblems. Incumbent may be exposed to communicable diseases. Incumbent is required tocomply with Employee Health Program guidelines including current immunization status ofidentified communicable diseases and safety precautions are sometimesnecessary, such as use of personal protective equipment as required by hospital policy. Thework environment involves moderate risks of exposure to infectious disease,radiation, electrical hazards, irritant chemicals and explosive gases. Customer Service Consistently demonstrates superior customer service skills topatients/customers by demonstrating characteristics that align with CIHA’s guidingprinciples and core values. Ensure excellent customer service is provided to allpatients/customers by seeking out opportunities to be of service.