Care Manager I-TCL (Full Time, Hybrid, Mecklenburg County, North Carolina Based)

About the role

The Care Manager l-TCL ensures that individuals and families with special health care needs receive integrated whole-person care management, including coordinating across physical health, behavioral health, pharmacy and unmet health-related resource needs to ensure they are linked to services and supports in an effort to maximize potential outcomes and decrease the unnecessary use of hospitals and emergency services.

Responsibilities

• Complete Assessment/Planning
  • Comprehensive assessments or Care Needs Screening at enrollment, yearly or at changes in condition
  • Develop Plans of Care derived from the completed assessments
• Demonstrate commitment to whole person/integrated care
  • Assign interventions/plans of care to applicable Alliance Care Management team member to meet identified member needs, for monitoring, and/or service engagement activities
  • Submit referrals to the CCM when a physical health or behavioral health need indicates medical and/or pharmaceutical complexity
  • Assign Plan of Care activities to Community Health Worker if member has identified Social Determinants of Health (SDOH), disparities and/or complex payer issues
  • Afford support and monitoring to members
  • Collaborate with other team members to ensure smooth transition to appropriate level of care when needed
  • Communicate with member to check on status, verify care needs are met and update the Plans of Care, as needed
  • Provide follow up coordination with key stakeholders to promote engagement
• Support and Monitoring to Members
  • Schedule initial contact with member for purpose of assessment and engagement
  • Schedule face to face, virtual, and telephonic meeting with member/guardian to provide education about Alliance Health Plan, care teams, resources, and 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
  • Refer members who are in crisis/institutional setting and require assistance with returning to community based services to the Integrated Health Consultant or applicable care team member
  • Recognize and report critical incidents and provider quality concerns to supervisors and Quality Management Department
• Documentation
  • Obtain and upload all supporting documentation, Legally Responsible Person (LRP) verification, and release of information that will improve care management activity on behalf of the member
  • Open new episodes in JIVA when needed and schedule initial contact with member to verify accuracy of demographic information and initiate the rapport building process
  • Document all applicable member updates and activities per organizational procedure
  • Escalate complex cases and cases of concern to immediate supervisor
  • Share appropriate documentation with all involved stakeholders as consent to release is granted
  • Maintain required contacts with member/legally responsible person per state contractual requirements meeting minimum expectations
• TCL Ongoing Monitoring
  • Complete TCL monitoring requirements as outlined in service desk reference to support member tenancy, health, safety and community integration, property and provider coordination, technical assistance, service linkage, addressing barriers, review the monthly tenancy checklist and routine reporting
  • Aid the Post-Transition Engagement Specialist with contact information, as needed, so the 11- month and 24 - month Quality of Life surveys can be completed by their due date
• Tenancy Stability/Rehousing
  • Support to the Supportive Housing team to secure documents required to maintain TCL tenancy, including annual inspections, biannual recertification, income adjustments, and monthly housing checklist, as needed
  • Complete and follow up on any voucher application needs
  • Technical assistance to providers during the re-housing process
  • Complete, at minimum, monthly follow up with providers when a member loses TCL housing and requests a rehouse
  • Aid provider with completing the required documents for members moving to Bridge or Hotel Program
  • Update State and Alliance Health data systems when rehousing is confirmed
  • Education member about Individual Placement and Support-Supported Employment (IPS-SE) for employment referral, community integration and education referral and support
• Housing Separations
  • Complete required discharge tasks when member leaves TCL housing
• Travel
  • Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
  • Travel to meet with members, providers, stakeholders, attend court hearings etc. is required

Requirements

• Bachelor’s degree from an accredited college or university in Human Services field and two (2) years of post-bachelor’s degree mh/dd/sa experience with the population served
• Or Bachelor’s degree from an accredited college or university in Non-Human Services field and four (4) years of post-bachelor’s degree mh/dd/sa experience with the population served
• Or Master’s Degree from an accredited college or university in Human Services field and one (1) year of post graduate degree mh/dd/sa experience with the population served
• Or Fully or Provisionally Licensed in the State of North Carolina as a LCSW, LCMHC, LPA, or LMFT
• Or Licensed Registered Nurse (RN) in the State of North Carolina with four (4) years of mh/dd/sa experience with the population served

Preferred

• NACCM, NADD-Specialist and/or CBIS Certification