I/DD Community Integration Care Manager (Full Time, Hybrid, Morrisville, North Carolina Based)

I/DD Community Integration Care Manager (Full Time, Hybrid, Morrisville, North Carolina Based) The IDD Community Integration CM position provides a critical support to Alliance members with I/DD to successfully integrated from an institutional setting into independent community living settings of their choice. Responsibilities include building relationships and rapport with members and providers through in reach activities, with ongoing support transitioning into the community, and care management once in the community. Additional diversion planning and coordination is provided to members for their success in remaining in a community setting. This role is hybrid, requiring facility visits and home visits to meet member needs.

This is a full-time hybrid opportunity. T is no expectation of coming into the office routinely, however, the selected candidate must be available to report onsite to the Alliance Office (Morrisville, North Carolina) for business meetings as needed. The successful candidate will also be required to travel monthly throughout North Carolina to meet with members, providers and/or state developmental centers.

Responsibilities & DutiesAssessment & Monitoring

• Document member and/or legally responsible person (LRP) consent to participate in the transition process and care management efforts
• Within defined timelines, complete assessment of the member preferences and needs related to integrated community living through active listening, meaningful conversation, motivational interviewing, and the use of open-ended questions
• Assess the whole person including physical, psychological, social, environmental, and spiritual needs
• With appropriate consent, as applicable, collaborate with formal and informal caregivers or support network, providers, and others in the member's interdisciplinary healthcare team to inform the assessment
• Document the assessment findings, including not limited to, the member's support systems (professional and informal), primary concerns, strengths, priorities, care need gaps, social needs, goals, etc.
• Document member and/or LRP agreement regarding the identified care needs, opportunities, and goals for intervention identified through the assessment process
• During member engagements and through available data related to resource utilization and quality metrics, monitor the member's condition and response to the care plan and interventions
• Document ongoing collaboration and engagement with the member, LRP, and others involved in the member's care and support to reflect the member's response to interventions and the care plan
• Document new findings, barriers to care and services, and/or continued effectiveness of the current care plan, with notation of member's understanding of and agreement with the assessment
• Through ongoing, routine and ad hoc follow-up with the member and/or their support network, monitor progress towards goals and/or revise goals appropriately to be relevant and realistic with member input and agreement
• Collaborate with member/LRP on progress towards goals met to determine appropriate time to end current episode of care management once transitioned into a community living setting of their choiceCare Planning
• Based on assessment and member identified priorities, develop a member centric and agreed upon care plan in collaboration with appropriate and applicable formal and informal caregivers or support network, providers, and others in the member's interdisciplinary healthcare team
• Use of a member-centric, collaborative partnership approach that is responsive to the individual member's culture, preferences, needs, and values
• Develop care plan with a comprehensive, holistic, and compassionate approach to care delivery that integrates a member's medical, behavioral, social, psychological, functional, and other needs
• Consideration for the member's care needs, barriers, and opportunities in development of the care plan
• In collaboration with the member and their support network (formal and informal) include prioritized goals and outcomes to be achieved with associated interventions or actions needed to reach the goals
• Include appropriate, relevant, and realistic goals to align with member needs and priorities
• With reassessment, new findings, or member request, make any revisions or modifications needed to the care plan goals or interventions to influence positive member outcomes. Review with member for understanding of and agreement with revisions or updates to the care planIn Reach, Transition, Care Coordination & Collaboration
• Facilitating awareness of and connections with community supports and resources to support successful integration into and sustained success with community living
• Referral to community & social support services, including providing referral, information, and assistance and follow-up in obtaining and maintaining community-based resources and social support services while providing comprehensive assistance securing key health-related services (e.g., filling out and submitting applications)
• Foster safe and manageable navigation through the healthcare system to enhance the member's timely access to services and achieve desired outcomes
• Coordinate care, services, resources, and health education specified in the planned interventions
• Ongoing communication and collaboration with the member's formal and informal support systems (with appropriate consent), providers, and the interprofessional healthcare team
• Provide evidence of facilitation, coordination, and collaboration to support transitional care management activities
• Facilitate and coordinate with connection to community, local and state resources, primary care providers, members of the interdisciplinary healthcare team, and other relevant stakeholders
• Document the collaborative and transparent communication with the healthcare team membersAdvocacy
• Document adnce to member privacy and confidentiality mandates during all aspects of facilitation, coordination, communication, and collaboration within and outside the member's primary setting of care
• Provide education and guidance on self-determination and self-management. Promoting informed and shared decision-making, autonomy, growth, and self-advocacy
• Connect the member and/or their informal caregiver supports 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 and their caregivers regarding their rights, protections, and responsibilities, including the right to change providers, the grievance and complaint resolution process, and fair hearing processes
• Educate other healthcare and service providers in recognizing and respecting the member's needs, strengths, and goals
• Recognize, prevent, and eliminate disparities in accessing high quality care
• Advocate for the least restrictive appropriate levels of care, timely and well-coordinated transitions, and allocations of resources to optimize outcomes
• Identify system barriers to quality care, timely and appropriate services, in the least restrictive setting, escalating identified barriers to direct supervisor for additional support
• Recognize potential rising risk or escalation and seek appropriate consultation with clinical operations and leadership such as, not limited to, medical directors, registered nurses, pharmacy, legal, compliance, organizational senior leadership, etc.
• Actively participate in interdisciplinary care team rounds, peer conferences, ad hoc staffing, high-risk member committee, and other consultations as appropriate to the member's needs and circumstancesHealth Promotion
• Assess readiness for change and provide the appropr.

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