Tailored Plan Care Manager

Job DetailsJob Location: 917 N 4th St - Wilmington, NC 28401SUMMARY: The Tailored Plan Care Manager is an integral part of MedNorth Health Center’s team approach to integrated care for patients with Intellectual or Developmental Disabilities (I/DD) and/or Behavioral Health challenges (severe and persistent mental health and/or substance use diagnoses). The Tailored Plan Care Manager promotes whole person, integrated care by planning, coordinating, tracking, closing gaps in care and monitoring care to individuals to achieve the key goals of Tailored Plan Care Management. The Tailored Plan Care Manager interacts with all members of the healthcare team to keep the lines of communication open and helps improve patient outcomes. PRIMARY DUTIES and RESPONSIBILITIES: The Primary Duties and Responsibilities include the following: (other duties may be assigned): Develop, review and complete comprehensive assessments that are patient-centered and considers the total individual, inclusive of medical, biopsychosocial, behavioral, spiritual and cultural needs of the enrolled population, throughout the continuum of care to improve their health outcomes Work with patients/caregivers, to identify and address behavioral, social, cultural, and environmental strengths and barriers as it relates to his/her diagnosis, treatment, and access to care Implement Care Management interventions, set goals, and develop the plan of care based on transitional care discharge plans/instructions, the comprehensive assessment and patient goals Implement patient-centered plans using therapeutic skills and techniques such as trauma-informed care, motivational interviewing, strengths-based, and solution-focused modalities Facilitate and provide education to patients/families about clinical diagnosis, medications, available resources, prevention, and risk factors to achieve optimal self-management Monitor quality and effectiveness of interventions to the enrolled populations by setting patient-centered SMART goals in collaboration with the patients’ and families’ identified goals Delegate tasks and referrals to members of the care management team appropriately, accurately and timely according to established workflows Make appropriate referrals to community resources and empower individuals to be responsible for their own healthcare and personal needs. Referrals will focus on behavioral health, physical health, and Social Determinants of Health (SDOH) needs. SDOH needs are related, but not limited, to economic stability, education access and quality, health care access and quality, community connection and engagement, and safety in communities. Coordinate follow-up services for patients with recent inpatient hospitalization or Emergency Department visits within 24 business hours of discharge. Coordinates after care needs for transitions in care such as release from incarceration, change in housing, or other life transitions. Identify, create and coordinate emergency crisis response plan as necessary, following agency policies related to crisis. Participate in post crisis team debriefing and provide feedback on ways to prevent future crisis for the person served. Serve as an advocate and liaison among the patient/family, community services, primary care providers, specialists, and other care team members to coordinate services Engage and maintain collaborative relationships with community provider agencies that promote quality care and cost-effective health care utilization Communicate effectively with individuals receiving services, providers, and other natural supports as needed. Provide education regarding services to all parties involved in the care and support of the patient. Establish collaborative relationships with integrated care team members and community resources within the assigned geographical region to improve resource linkage. Review data to identify and determine appropriateness for services, which includes monitoring utilization, reporting, clinical measurement data and compliance issues. Demonstrate knowledge of and comply with all agency policies and procedures, as well as service definitions related to specific program areas. Maintain trainings as required and requested. Participate in Quality Improvement (QI) projects, to improve service delivery and costs of care, on an as needed basis. Driving and travel may be required Maintain appropriate and timely documentation in the Care Management documentation platform, in accordance with organizational policies and procedures Abide by company policies and HIPAA regulations Perform home visits as required by clinical judgment, patient needs and policies and procedures     Willingly performs other duties as assigned. Corporate Compliance: It is an essential job element that everyone be compliant with the full law and fully cooperate with the compliance program without fear of retaliations from the organization. SUPERVISORY RESPONSIBILITIES:  May supervise care manager extenders as assigned and appropriate. QUALIFICATION REQUIREMENTS: The requirements listed below are representative of the knowledge skills, and/or ability desired: EDUCATION AND/OR EXPERIENCE:  To be a care manager for the Tailored Care Management (TCM) Program Individuals must meet the North Carolina definition requirements for a Qualified Professional (QP) set out in 0A-NCAC 27G .0104. These requirements are listed below. "Qualified professional" means, within the mh/dd/sas system of care either: (a)           an individual who holds a license, provisional license, or certificate issued by the governing board regulating a human service profession, including a registered nurse who is licensed to practice in the State of North Carolina by the North Carolina Board of Nursing who also has four years of full-time accumulated experience in mh/dd/sa with the population served; (b)           a graduate of a college or university with a Masters degree in a human service field and has one year of full-time, pre- or post-graduate degree accumulated supervised mh/dd/sa experience with the population served, or a substance abuse professional who has one year of full-time, pre- or post-graduate degree accumulated supervised experience in alcoholism and drug abuse counseling; (c)           a graduate of a college or university with a bachelor's degree in a human service field and has two years of full-time, pre- or post-bachelor's degree accumulated supervised mh/dd/sa experience with the population served, or a substance abuse professional who has two years of full-time, pre- or post-bachelor's degree accumulated supervised experience in alcoholism and drug abuse counseling; or (d)           a graduate of a college or university with a bachelor's degree in a field other than human services and has four years of full-time, pre- or post-bachelor's degree accumulated supervised mh/dd/sa experience with the population served, or a substance abuse professional who has four years of full-time, pre- or post-bachelor's degree accumulated supervised experience in alcoholism and drug abuse counseling. KNOWLEDGE, SKILLS AND ABILITIES: Required: Strong interpersonal and written/verbal communication skills Conflict management and resolution skills High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance. Strong problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers. Ability to organize multiple tasks and priorities Ability to change the focus of activities to meet changing priorities Preferred: Knowledge of Medicaid basic, enhanced MHSUD, and waiver benefits plans Knowledge of community specific financial planning resources Knowledge of regulations and statutes specific to 1915(b) and (c) waiver services including licensure type required for facility-based services, and staffing and supervision requirements (LTS and TBI Care Workers only) Knowledge of and skilled in the use of Motivational Interviewing techniques Detail oriented Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is strongly preferred Must demonstrate flexibility and adaptability. LANGUAGE SKILLS:  Ability to speak English fluently.  The ability to speak other languages is a plus. PHYSICAL DEMANDS:    The physical demands described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand, walk, talk, and hear, use hands and fingers, handle or feel.  The employee is occasionally required to stoop, kneel, crouch or crawl.  The employee is frequently required to lift and/or move up to 20 pounds. The special vision requirements for this job are close vision (clear vision at 20 inches or less), as well as distant vision and color vision (ability to identify and distinguish colors). WORK ENVIRONMENT: The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions for this job.  Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. MedNorth Health Center provides comprehensive health care services, inside a multi-cultural medical/dental clinic, to all individuals; insured, uninsured, and underinsured.  The building is heated in winter and air conditioned in the summer with noise levels of moderate to loud.  We serve patients who speak multiple languages and who may need the assistance of an interpreter.  In this position one may be subject to exposure to copier toner, correction fluid, bright fluorescent lighting, and continuous personal computer exposure. This job is a Blood borne Pathogens risk category III position. GENERAL EXPECTATIONS: The employee is expected to attend work on a daily basis and to be at work on time. The employee is expected to be a team player. The employee is expected to report absences in accordance with personnel policies and procedures. The employee's work is expected to be accurate, neat, and thorough, and completed on time. The employee is expected to have a positive attitude, be cooperative, and considerate of others. The employee is expected to be dependable and is expected to accept responsibility for assignments and duties given. The employee is expected to dress and act in a professional manner and adhere to all safety standards. The employee is expected to participate in staff meetings, be courteous and polite with patients and other staff. The employee is expected to maintain confidentiality.    Qualifications