Innovations Care Manager (Rowan and Forsyth County, NC)
Company: Vaya Health
Location: Asheville
Posted on: January 24, 2025
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Job Description:
LOCATION: Remote - must live in or near Rowan and/or Forsyth
County, North Carolina. Incumbent in this role must live in North
Carolina or within 40 miles of the NC border. This position
requires travel. GENERAL STATEMENT OF JOBInnovations Care Manager
(Innovations CM) is responsible for providing proactive
intervention and coordination of care to eligible Vaya Health
members and recipients ("members") to ensure that these individuals
receive appropriate assessment and services. The Innovations CM
works with the member and care team to alleviate inappropriate
levels of care or care gaps through assessment, multidisciplinary
team care planning, linkage and/or coordination of services needed
by the member across the MH, SU, intellectual/ developmental
disability ("I/DD"), traumatic brain injury ("TBI") physical
health, pharmacy, long-term services and supports ("LTSS") and
unmet health-related resource needs networks. Innovations CMs
support and may provide transition planning assistance to state,
and community hospitals and residential facilities and track
individuals discharged from facility settings to ensure they follow
up with aftercare services and receive needed assistance to prevent
further hospitalization. This is a mobile position with work done
in a variety of locations, including members' home communities. The
Innovations CM also works with other Vaya staff, members,
relatives, caregivers/ natural supports, providers, and community
stakeholders. As further described below, essential job functions
of the Innovations CM include, but may not be limited
to:Utilization of and proficiency with Vaya's Care Management
software platform/ administrative health record ("AHR")Outreach and
engagementCompliance with HIPAA requirements, including
Authorization for Release of Information ("ROI")
practicesPerforming Health Risk Assessments (HRA): a comprehensive
bio-psycho-social assessment addressing social determinants of
health, mental health history and needs, physical health history
and needs, activities of daily living, access to resources, and
other areas to ensure a whole person approach to careAdherence to
Medication List and Continuity of Care processesParticipation in
interdisciplinary care team meetings, comprehensive care planning,
and ongoing care managementTransitional Care ManagementDiversion
from institutional placement This position is required to meet NC
Residency requirements as defined by the NC Department of Health
and Human Services ("NCDHHS" or "Department"). This position is
required to live in or near the counties served to effectively
deliver in-person contacts with members and their care teams.
ESSENTIAL JOB FUNCTIONSAssessment, Care Planning and
Interdisciplinary Care Team:Ensures identification, assessment, and
appropriate person-centered care planning for members.Links members
with appropriate and necessary formal/ informal services and
supports across all health domains (i.e., medical, and behavioral
health home).Meets with members to conduct the HRA and gather
information on their overall health, including behavioral health,
developmental, medical, and social needs. Administer the PHQ-9,
GAD, CRAFT, ACES, LOCUS/CALOCUS, and other screenings within their
scope based on member's needs. The Innovations CM uses these
screenings to provide specific education and self-management
strategies as well as linkage to appropriate therapeutic
supports.The assessment process includes reviewing and transcribing
member's current medication and entering information into Vaya's
Care Management platform, which triggers the creation of a
multisource medication list that is shared back with prescribers to
promote integrated care.Supports the care team in development of a
person-centered care plan ("Care Plan") to help define what is
important to members for their health and prioritize goals that
help them live the life they want in the community of their
choice.Ensure the Care Plan includes specific services to address
mental health, substance use, medical and social needs as well as
personal goalsEnsure the Care Plan includes all elements required
by NCDHHSUse information collected in the assessment process to
learn about member's needs and assist in care planningEnsure
members of the care team are involved in the assessment as
indicated by the member/LRP and that other available clinical
information is reviewed and incorporated into the assessment as
necessaryWork with members to identify barriers and help resolve
dissatisfaction with services or community-based
interventionsReviews clinical assessments conducted by providers
and partners with Innovations CM, LP and Manager, IDD Care
Management, LP or Director, Care Management for clinical
consultation as needed to ensure all areas of the member's needs
are addressed. Help members refine and formulate treatment goals,
identifying interventions, measurements, and barriers to the
goals.Ensures that member/legally responsible person ("LRP") is/are
informed of available services, referral processes, etc. (i.e.
Individual/Family Direction for Innovations participants),
processes (e.g., requirements for specific service), etc.Provide
information to member/LRP regarding their choice in choosing
service providers, ensuring objectivity in the process.Works in an
integrated care team including, but not limited to, an RN
(Registered Nurse) and pharmacist along with the member to address
needs and goals in the most effective way ensuring that member/LRP
have the opportunity to decide who they want involved.Supports and
may facilitate Care Team meetings where member Care Plan is
discussed and reviewed.Solicits input from the care team and
monitor progress.Ensures that the assessment, care plan and other
relevant information is provided to the care team. Reviews
assessments conducted by providers and consults with clinical staff
as needed to ensure all areas of the member's needs are
addressed.Update Care Plans and Care Management assessment at a
minimum of annually or when there is a significant life change for
the member.Supports and assists with education and referral to
prevention and population health management programs.Participate in
multidisciplinary huddles including RN, Pharmacist, M.D. and case
staffings to present case to address barriers, identify need for
specialized services to meet member needs and receive support and
feedback regarding interventions for medical, behavioral health,
I/DD, medication, and other needs and provide support to other Care
Managers.Risk Management- Proactively ensures that individuals
identified as a Special Needs enrollee that have treatment needs or
require regular monitoring have a Behavioral Health Clinical Home
and a Medical Home.Works with the member/LRP and care team to
ensure the development of a Care Management Crisis Plan for the
member that is tailored to their needs and desires, which is
separate and complementary to the behavioral health provider's
crisis plan.Provides crisis intervention, coordination, and care
management if needed while with members in the community.Supports
Transitional Care Management responsibilities for members
transitioning between levels of care.Coordinates Diversion efforts
for members at risk of requiring care in an institutional
setting.Consults with care management licensed professionals, care
management supervisors, and other colleagues as needed to support
effective and appropriate member care. Support
Monitoring/Coordination, Documentation and Fiscal
Accountability:Serves as a collaborative partner in identifying
system barriers through work with community stakeholders.Manages
and facilitates Child/Adult High-Risk Team meetings in
collaboration with providers, stakeholders and other community
supports as appropriate. Participates in cross-functional clinical
and non-clinical meetings and other projects as needed/ requested
to support the department and organization.Participates in routine
multidisciplinary huddles including RN, Pharmacist, M.D. to present
complex clinical case presentation and needs, providing support to
other CMs (Care Manager) and receiving support and feedback
regarding CM interventions for clients' medical, behavioral health,
intellectual /developmental disability, medication, and other
needs.Works in partnership with other Vaya departments to identify
and address gaps in services/ access to care within Vaya's
catchment.Works with Innovations CM, LP and IDD Manager- LP in
participating in other high risk multidisciplinary complex case
staffing as needed to include Vaya CMO/ Deputy CMO, Utilization
Management, Provider Network, and Care Management leadership to
address barriers, identify need for specialized services to meet
client needs within or outside the current behavioral health
system.Ensures the health and safety of members receiving care
management, recognize and report critical incidents, and escalate
concerns about health and safety to care management leadership as
needed.Ensure that services are monitored (including direct
observation of service delivery) in all settings at required
frequency and for compliance with standards.Make
announced/unannounced monitoring visits, including nights/weekends
as applicable. Monitors provision of services to informally measure
quality of care delivered by providers and identify potential
non-compliance with standards.Supports problem-solving and
goal-oriented partnership with member/LRP, providers, and other
stakeholders Promotes member satisfaction through ongoing
communication and timely follow-up on any concerns/issues.Supports
and assists members/families on services and resources by using
educational opportunities to present information.Educate
members/families on methodology for budget development, total
dollar value of the budget and mechanisms available to modify the
individual budget. Monitor services to ensure that they are
delivered as outlined in individualized service plan and address
any deviations in service.Ensure that service orders/doctor's
orders are obtained, as applicable.Verifies member's continuing
eligibility for Medicaid, and proactively responds to a member's
planned movement outside Vaya's catchment area to ensure changes in
their Medicaid County of eligibility are addressed prior to any
loss of service. Alerts supervisor and other appropriate Vaya staff
if there is a change in member Medicaid eligibility/status.
Proactively and timely creates and monitors documentation within
the AHR to ensure completeness, accuracy and follow through on care
management tasks.Coordinate Medicaid deductibles, as applicable,
with the individual/guardian and provider(s).Proactively monitor
own documentation to ensure that issues/errors are resolved as
quickly as possible.Ensure accurate/timely submission of Service
Authorization Requests (SARS) for all Vaya funded
services/supports.Works with Innovations CM, LP and Manager,
Innovations Care Management, LP to ensure all clinical and
non-clinical documentation (e.g. goals, plans, progress notes,
etc.) meet all applicable federal, state, and Vaya requirements,
including requirements within Vaya's contracts with NCDHHS. Alert
supervisor and other appropriate Vaya staff if there is a change in
member Medicaid eligibility/status. Participates in all required
Vaya/ Care Management trainings and maintains all required training
proficiencies. Other duties as assigned. KNOWLEDGE, SKILL &
ABILITIESAbility to express ideas clearly/concisely and communicate
in a highly effective mannerAbility to drive and sit for extended
periods of time (including in rural areas)Effective interpersonal
skills and ability to represent Vaya in a professional
mannerAbility to initiate and build relationships with people in an
open, friendly, and accepting mannerAttention to detail and
satisfactory organizational skillsAbility to make prompt
independent decisions based upon relevant factsA result and
success-oriented mentality, conveying a sense of urgency and
driving issues to closureComfort with adapting and adjusting to
multiple demands, shifting priorities, ambiguity, and rapid
changeThorough knowledge of standard office practices, procedures,
equipment, and techniques and intermediate to advanced proficiency
in Microsoft office products (Word, Excel, Power Point, Outlook,
Teams, etc.), and Vaya systems, to include the care management
platform, data analysis, and secondary researchUnderstanding of the
Diagnostic and Statistical Manual of Mental Disorders (current
version) within their scope and have considerable knowledge of the
MH/SU/IDD/TBI service array provided through the network of Vaya
providers. Experience and knowledge of the NC Medicaid program, NC
Medicaid Transformation, Tailored Plans, state-funded services, and
accreditation requirements are preferred.Ability to complete and
maintain all trainings and proficiencies required by Vaya, however
delivered, including but not limited to the following:BH I/DD
Tailored Plan eligibility and servicesWhole-person health and unmet
resource needs (Adverse Childhood Experiences, Trauma, cultural
humility)Community integration (Independent living skills;
transition and diversion, supportive housing, employment,
etc.)Components of Health Home Care Management (Health Home
overview, working in a multidisciplinary care team, etc.)Health
promotion (Common physical comorbidities, self-management, use of
IT, care planning, ongoing coordination)Other care management
skills (Transitional care management, motivational interviewing,
Person-centered needs assessment and care planning, etc.)Serving
members with I/DD or TBI (Understanding various I/DD and TBI
diagnoses, HCBS, Accessing assistive technologies, etc.)Serving
children (Child and family centered teams, understanding of the
"System of Care" approach)Serving pregnant and postpartum women
with Substance Use Disorder (SUD) or with SUD historyServing
members with LTSS needs (Coordinating with supported employment
resources)Job functions with higher consequences of error may be
identified, and proficiency demonstrated and measured through job
simulation exercises administered by the supervisor where a minimum
threshold is required of the position. EDUCATION & EXPERIENCE
REQUIREMENTSBachelor's degree in a field related to health,
psychology, sociology, social work, nursing or another relevant
human services.
PHYSICAL REQUIREMENTSClose visual acuity to perform activities such
as preparation and analysis of documents; viewing a computer
terminal; and extensive reading. Physical activity in this position
includes crouching, reaching, walking, talking, hearing and
repetitive motion of hands, wrists and fingers. Sedentary work with
lifting requirements up to 10 pounds, sitting for extended periods
of time. Mental concentration is required in all aspects of work.
Ability to drive and sit for extended periods of time (including in
rural areas) RESIDENCY REQUIREMENT: The person in this position is
required to reside in North Carolina or within 40 miles of the
North Carolina border. SALARY: Depending on qualifications &
experience of candidate. This position is non-exempt and is
eligible for overtime compensation.
DEADLINE FOR APPLICATION: Open Until Filled
APPLY: Vaya Health accepts online applications in our Career
Center, please visit .
Vaya Health is an equal opportunity employer.
Keywords: Vaya Health, Rock Hill , Innovations Care Manager (Rowan and Forsyth County, NC), Executive , Asheville, South Carolina
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