IDD TBI LTSS Care Manager Position Available In Swain, North Carolina

IDD TBI LTSS

Care Manager 3.5 3.5 out of 5 stars 1 Hospital Rd # C-268, Cherokee, NC 28719

Job Title:

Tribal Option Care Manager –

IDD/TBI/LTSS Job Code:

IDD/TBI/LTSS CM

Department:

Primary Care Division:

Nursing Salary Level:

Non-Exempt 12 Reports to:

IDD/TBI/LTSS

Supervisor/HOP Supervisor/Assistant Director of Care Management/Director of Care Management Last Revised:

May 2025 Primary Function The individual provides care management to individuals of all ages who have been diagnosed with an IDD (Intellectual & Developmental Disabilities) /TBI (Traumatic Brain Injury), based on the DSM V or subsequent editions, or those who have been identified as needing Long Term Services and Supports (LTSS). The Care Manager will complete Care Needs Screenings (CNS) as necessary and will be primarily responsible for completing the Comprehensive Assessment on eligible members who have

IDD/TBI/LTSS

needs. The Care Manager will be primarily responsible for assisting the member develop their care team and the completion of the Care Plan/ISP based on the needs and desires of the member/legally responsible person, team and their support system. Plans will be person centered in nature and reflect all the areas of support needed by the member. The Care Manager will ensure level of care assessments are completed and is responsible for coordinating the member’s whole person care (Physical, Behavioral, pharmacy—BH, IDD, TBI, and Unmet Social or Health-Related Resource Needs, including but not limited to vocational, education, social supports, personal safety, housing and food insecurity). This position may be required to complete care management activities related to their member being Tailored Plan eligible which would require being proficient in the Behavioral Health traditional care requirement set forth by NCDHHS. The overall goal of the Tailored Care Management model is improved health outcomes for eligible individuals. The design of the model has been shaped by the following guiding principles: Broad access to care management . Care Management is available to all eligible individuals continuously, with limited exceptions. Dedicated care manager taking an integrated, whole-person approach. To the maximum extent possible, each enrolled individual will receive integrated, whole-person care management from a dedicated care manager with expertise and training in addressing behavioral health, I/DD, LTSS and/or TBI needs in addition to physical health needs and unmet health-related resource needs. Person and family-centered planning. Care planning for individuals will be person-centered and will consider their unique needs. Parents, other family members, and caregivers can also serve as part of the individual’s care team, with the individual’s consent. Tailored Care Management aligns with the North Carolina System of Care framework. Job Description Utilizes best practice models to identify, incorporate or develop best practices for panel management. Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies. Manages assigned panel by addressing and resolving acute care needs and chronic care needs through a team-based approach. Utilizes the electronic health record to assist with tracking and monitoring the appropriate follow-up of members targeting specific health indicators. Utilizes the care management platform for documentation of care management functions such as a care needs screening, comprehensive assessment, and care planning. Utilizes different available platforms/dashboards for population health and related interventions and innovations for management of care needs or gaps in care Utilizes NC Health connects for information gathering and data collections for management of care needs or gaps in care Coordinates and follows up on referrals to outside specialty providers, recent ED visits, and ICC visits. Coordinates and follows up on recent admissions and discharges. Provides member education, advice and information on health assessment, disease processes, medications, treatment plans and available community resources. Assesses member needs using established clinical guidelines, protocols, and pathways. Collects data from relevant sources (member, family, or caregiver) regarding the biological, psychological, social and cultural factors that might influence and impact the health status of the individual and utilizes this data in member center care plan development. Interprets data and recognizes existing relationships between data collected and the member’s health status and treatment regimen and determines the member’s need for immediate interventions. Initiates individualized care plan based on assessment of the member for specific illnesses, injuries, and diseases Social Determinants of Health (SDoH) and human behavior while adhering to appropriate standards of care. Develops individualized plan of care with input from the member, the member’s family, pod members, and anyone else the member requests to be included for those members considered “high risk.” Develops expected member outcomes that are observable and within an adequate period, and are congruent with the member’s present and potential physical capabilities and behavioral patterns. Responsible for assisting with establishing a multidisciplinary care team for each member. Coordinates closely with each member’s primary care provider (PCP), and, as appropriate, care manager extenders, assigned County Child Welfare worker, EBCI Family Safety Program staff, CIHA Care Team, family members and guardians to manage the member’s health care needs. Assumes coordination responsibility for transition planning. The care manager will make best efforts to contact the member during their stay in an inpatient psychiatric unit or hospital, Facility-Based Crisis, general hospital unit, or nursing facility and make best effort to contact the member on the day of discharge. Provides transitional care management during care transitions (including assisting individuals with transitioning from congregate or other intensive treatment settings to a foster care home or other community placement). Obtain a copy of the discharge plan for members being discharged from an inpatient psychiatric unit or hospital, Facility-Based Crisis, or general hospital unit, or nursing facility and review the discharge plan with the member and facility staff. Facilitate clinical handoffs. Responsible for ensuring members receive robust medication reconciliation and management. Assists the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management, and support medication adherence Directs the extender’s care management functions and ensure that the extender supports allowable activities (e.g., coordinating services/appointments by arranging transportation, etc.). Responsible for implementing the Healthy Opportunities Pilot (HOP) program for its HOP-eligible members Facilitates additional requirements for members obtaining 1915(i) services Duties specifically related to members who are

CFSP:

May be required to provide 24/7 support during emergencies or behavioral health crises, including working with County Child Welfare workers (or EBCI Family Safety Program staff) to secure immediate treatment services, as needed. Responsible for convening the care team on a regular basis (no less than twice per year, and more often, as appropriate) and sharing the care plan/ISP with the member’s care team and other representatives, as appropriate, to support delivery of the member’s needed health and health-related services. Required to coordinate closely with each member’s assigned County Child Welfare worker to share relevant health and health-related information Collaborate with County Child Welfare workers as needed in the development of the NCDSS-required transitional living plan and 90-day transition plan. Duties specifically related to

I/DD, TBI, and LTSS:

Obtain releases/documentation and provide to all stakeholders involved. Obtain clinical supporting documentation, legal/guardianship verification, and necessary consents to exchange/release information Ensure that service orders/doctor’s orders are obtained, as applicable Verify ongoing service adherence with member and/or guardian Monitor ISP implementation and resolve or escalate issues as needed Monitor members at least quarterly to ensure that any restrictive interventions (including protective devices used for behavioral support) are written into the Care Plan/ISP and the Positive Behavior Support Plan; Monitor for HCBS compliance Notify Tailored Plan/LME/MCO of updates to eligibility and/or need for 1915(i) services. Provide education and support, to individuals and LRP, in learning about and exercising rights, explanation of the grievance and appeals process, available service options, providers available to meet their needs, and payer requirements that may impact service connection and maintenance. Escalate complex cases and cases of concern to the Supervisor. Participate and complete all required agency trainings and meetings, as well as all required care management-based trainings from the State, Technical Assistance entity or payor and within required timeframes as assigned. Travel to various community locations, other agencies and other outreach destinations as necessary to meet the members’ needs. Maintain all certification(s) or licensure required for the position. Demonstrate awareness and knowledge of and comply with all agency policies and procedures, as well as state and federal statutes and regulations related to care management. Meet at least minimum standards of monthly contacts and demonstrate ability to effectively engage with members. Participate in agency’s twenty-four (24) hour coverage around care management providing for coverage for services, consultation or referral as needed and arrange treatment for emergency medical conditions including behavioral health crises. Specifically, coverage will include the ability to share information such as care plans and psychiatric advance directives and coordinate care to place the member in appropriate setting during urgent and emergent events. May be subject to on-call and callback. May be necessary to work when administrative leave is granted if member care would be compromised. The incumbent will be evaluated annually on his/her ability to identify, assess, analyze, and evaluate data and solve problems through the CIH Performance Appraisal System. Education, Licensure, Certification, and Experience Care Managers serving all members must have the following minimum qualifications: Bachelor’s or Associates degree in nursing (RN) from an accredited program, or a Bachelor’s degree in a field related to health, psychology, sociology, social work, another relevant human services area. AND Two years of experience working directly with individuals with behavioral health conditions (if serving members with behavioral health needs) or with an I/DD or a TBI (if serving members with I/DD or TBI needs); AND For care managers serving members with LTSS needs: two years of prior LTSS and/or HCBS coordination, care delivery monitoring and care management experience, in addition to the requirements cited above. (This experience may be concurrent with the two years of experience working directly with individuals with behavioral health conditions, and I/DD or TBI conditions above). AND in addition to the conditions above If applicant is an RN-must have an unrestricted valid Registered Nurse license within the state of North Carolina or a state that is accepted as reciprocity. Specific experience working with Native Americans preferred. Current Basic Life Support (BLS) minimally required. Can be acquired through the facility within 6 months following appointment to position. Applicant must have a valid North Carolina driver’s license. Job Knowledge Knowledge and ability to independently plan, manage, and organize work in order to meet priorities, accomplish work within established time frames and work in stressful situations. Knowledge of the occupational functions of multi-disciplinary health care team. Knowledge of the culture and medical health profile of the member population. Knowledge and ability to teach and counsel member/family on health maintenance and disease prevention. Knowledge of available health care programs and community resources. Knowledge of care management including screenings, assessments, development of care plans and knowledge of resources available to members at all levels including tribal, county, regional and state. Knowledge of LOC process, SIS for IDD and FASN assessment for TBI Knowledge of Medicaid basic, enhanced MH/SUD, and waiver benefits plans Knowledge of and skilled in the use of Motivational Interviewing and techniques Strong interpersonal and written/verbal communication skills 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 for decision making and person-centered planning High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance. Ability to make prompt, independent decisions based upon relevant facts Good organizational skills to prioritize duties and work with minimal levels of onsite supervision to consistently meet deadlines In addition, have a working knowledge of the special needs of members who fall into the category of being eligible for Tailored Care Management services which includes those members with care needs related to a behavioral health condition (including both mental health and substance use disorders), intellectual/developmental disability (I/DD), or traumatic brain injury (TBI). Expertise in the systems and tools that are fundamental to the transition to adulthood, including independent living skills (e.g., accessing food and transportation), post-high school education, housing and employment options, self-advocacy, health insurance coverage options after Medicaid eligibility ends and building natural supports. Complexity of Duties Complies also with federal, state, accrediting and local regulations. These guidelines are not always specifically applicable to the individual member or situation and independent 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 incumbent independently plans, schedules, and provides care in coordination with the medical care plan and Tribal Option Care plan and attempts to solve problems only within established procedures. This is done under the supervision of the CFSP Care Management Supervisor, the HOP Supervisor, the Assistant Director of Care Management, and the Director of Care Management. The work is evaluated for technical soundness and adherence to professional standards. Responsibility for Accuracy The incumbent has a positive effect upon the recovery of the member and is responsible for following policies and procedures, which serve as hospital guidelines and prevents errors from occurring. Errors can have a negative member outcome since the incumbent’s performance affects the health, recovery, and rehabilitation of members, and the quality of care provided. Evaluations and observations are used to modify and develop clinically appropriate treatment plans. Work can be verified or checked by the immediate supervisor, other health care providers or systems checks, but usually the responsibility for accuracy relies solely on the incumbent. Contacts with Others Contacts are with members, families, hospital personnel, and community agencies. Contacts with members, families, and hospital personnel are to exchange, provide, and obtain information concerning the member’s physical and psychosocial health care problems, and needs. The nurse uses teaching and counseling methods to influence and motivate member and family behavior. Contacts with other health care or related disciplines within the hospital are for the purpose of collaboration and consultation. Tact, courtesy, and professional conduct are required to maintain positive working relationships. Utmost sensitivity and confidentiality is required when dealing with members and families. Confidential Data The incumbent has access to highly confidential member medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and all other pertinent information that comes to his/her attention or knowledge. The Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action. Mental/ Visual/ Physical Work in the various services within the Primary Care department is mostly sedentary, yet requires walking, standing, bending, pushing, and lifting in helping members to and from beds, wheelchairs, and stretchers. These same activities are required in moving equipment and medical supplies. Will be subject to frequent interruptions requiring varied responses, which can cause distractions therefore, the incumbent must possess the ability to differentiate and prioritize many tasks at once. Environment Must be flexible in working hours. Work is performed in the clinic setting, which is responsible for treating members with a wide variety of medical problems. Incumbent may be exposed to communicable diseases. Incumbent is required to comply with Employee Health Program guidelines including current immunization status of identified communicable diseases and safety precautions are sometimes necessary, such as use of personal protective equipment as required by hospital policy. The work 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 to members/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all members/customers by seeking out opportunities to be of service.