Tribal Option Care Management Extender

About the role

Care management extenders serve individuals eligible for Tailored Care Management, Intellectual Developmental Delays/Traumatic Brain Injury (I/DD/TBI), Long Term Service or Supports (LTSS), or those in the Children and Families Specialty Program (CSFP). Their duties include helping members gain access to necessary care, such as medical, behavioral, social, and community services.

Responsibilities

• Represent care management when working with members, families, caregivers, and other entities.
• Provide care management functions according to CIHA policy, including person centered planning, referral and linkage, and monitoring and follow-up.
• Ensure care plan activities are carried out under the direction of the care manager or supervisor.
• Gather and document necessary information in the EHR and/or care management platform, including medical, physical and functional, psychosocial, behavioral, financial, social, cultural, environmental, legal, and vocational or educational areas.
• Document all significant events in the EHR and/or care management platform as prescribed by EBCI TO policies and procedures and quality assurance standards.
• Engage members in the person centered planning process to assist them in achieving desired outcomes, skills, and symptom reduction.
• Link clients to needed services and supports.
• Provide timely information to care team members regarding member status, progress, and safety.
• Collaborate with the medical staff and other health professionals to facilitate patient care, discharge, and follow-up.
• Aid the care team in providing consultation to patients and families on matters related to their limitations, finances, adjustments to medical conditions, and ongoing treatments.
• Attend staffing huddles and participate in discussions of client data and care plan/ISP changes.
• Facilitate consultations with various persons and organizations affecting the member, including schools, courts, probation officers, physicians, hospitals, medical care providers, law enforcement officers, social services, community agencies, etc.
• Support members in the office and community settings by participating in home visits with patients and staff, as needed.
• Collect and report data necessary for member care according to procedure and as directed by supervisor.
• Arrange visits to the member's new care setting after discharge/transition.
• Perform general outreach, engagement, and follow-up with members; coordinate services/appointments, and provide referrals and information on community-based resources and social support services.
• Participate in case conferences/Huddles and assess and address unmet health-related resource needs.
• Facilitate transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven calendar days, unless required within a shorter timeframe.
• Support the TO Care Managers as needed.

Requirements

• At least 18 years of age.
• A high school diploma or equivalent (e.g., GED, certificate of completion).
• One of the following requirements for individuals with Tailored Care Management eligibility and/or I/DD/TBI:
  • A person with lived experience with an I/DD or TBI with demonstrated knowledge of and direct personal experience navigating the North Carolina Medicaid delivery system.
  • A person with lived experience with a behavioral health condition who is a Certified Peer Support Specialist.
  • A parent or guardian of an individual with an I/DD or TBI or a behavioral health condition and has at least two years of direct experience providing care for and navigating the Medicaid delivery system on behalf of that individual (a parent/guardian cannot serve as an extender for their family member).
  • Two years of paid experience performing the types of functions described in the essential duties and responsibilities section above, with at least one year of paid experience working directly with the Tailored Care Management eligible population.
• One of the following requirements for individuals enrolled in CSFP:
  • A Certified Family Peer Specialist (Family Partners)
  • A Certified Peer Support Specialist
  • A Community health worker
• A valid drivers' license.
• Current Basic Life Support (BLS) certification.

Qualifications

• Knowledge of principles, techniques, and practices, and their application to meet complex needs of the members.
• Knowledge of a wide range of medical, behavioral, and psychosocial problems and linkage to treatment.
• Knowledge of governmental and private organizations and resources in the community.
• Knowledge of the impact of mental illness on patients’ ability to negotiate care recommendations, current care approaches, modalities of care, and substance abuse and other programs or services available to patients.
• Ability to establish rapport with a patient and apply techniques of engagement.
• Willingness to learn more about Cherokee culture/population and consider it when interacting with members.
• Ability to establish and maintain effective working relationships with patients and their families, other professional disciplines, and a variety of governmental and private resources and organizations in the community.
• Ability to express ideas clearly and concisely and plan and work effectively in a team.