The Care Manager l-TCL assures 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 by assuring that appropriate quality care is in place.

The Care Manager I – TCL focuses on a specified population of members utilizing health care services while ensuring all member health needs and referrals are attended to. The Care Manager l will collaborate with other community systems to work in partnership to support the identified population while working to assist member with remaining in their preferred housing per Transition to Community Living requirements.

This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office and within the communities served may be required.

Responsibilities & Duties

Complete Assessment/Planning

• Complete 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
• Assist individuals/legally responsible persons in choosing service providers; ensuring objectivity in the process
• Consistently evaluate appropriateness of services and ensure implementation of plan of care through information gathering and assessment at defined frequency of contact based on risk stratification
• Utilize person centered planning, motivational interviewing, and historical review of assessments in JIVA to gather information and to identify supports needed for the individual
• Assist in collecting data to be used to identify and address barriers as well as determine the effectiveness of care management/care coordination in reducing lengths of stay and use of emergency services
• Actively collaborate with members/legally responsible person, care team, service providers, and identified supports to ensure development of a plan that accurately reflects the individual’s needs and desired life goals consistent with best practices and working through the permanent supportive housing model

Provide 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
• Complete activities in JIVA related to Plans of Care developed from the Care Management Comprehensive Assessment or other assessments as deemed necessary
• Coordinate 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
• Promote customer satisfaction through ongoing communication and timely follow-up on any concerns/issues
• Verify that ongoing service adherence is maintained through monitoring meetings with member and/or guardian or provider
• Identify barriers to treatment and assist individuals with arranging appointments or linking to treatment providers
• Maintain required contacts with member/legally responsible person per state contractual requirements meeting minimum expectations
• Attend community, provider, stakeholder meetings as needed for member and/or as directed to support the needs of the health plan

Complete 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
• Obtain releases/documentation and provide to all stakeholders involved
• Maintain medical record compliance/quality in mandated systems (Jiva, Clive, TCLD)
• Proactively respond to an individual’s planned movement outside the Alliance geographic area, or other transition need, to ensure a smooth transition without lapse in care.
• Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meets state, agency documentation standards, and Medicaid requirements

Compliance with Alliance Policy and Procedure

• Adhere to all Alliance Organizational Policies and Procedures and Care Management Desk Procedures

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
• Assist 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

• Provide 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
  
• Provide 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
  
• Assist 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
  
• Educate 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

Minimum 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

Knowledge, Skills, & Abilities

• Person Centered Thinking/planning
• Knowledge of using assessments to develop plans of care
• Knowledge of Diagnostic and Statistical Manual of Mental Disorders
• Knowledge of LOC process, SIS for IDD and FASN assessment for TBI
• Knowledge of Medicaid Tailored Plan, Medicaid Direct, enhanced MHSUD, and waiver benefits plans
• Knowledge of and skilled in the use of Motivational Interviewing
• Proficient in Microsoft Office products (such as Word, Excel, Outlook, etc.)
• Strong interpersonal and written/verbal communication skills essential, including
• Conflict management and resolution skills
• High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance.
• Ability to make prompt, independent decisions based upon relevant facts

Employment for this position is contingent upon a satisfactory background and MVR (Motor Vehicle Registration) check, which will be performed after acceptance of an offer of employment and prior to the employee's start date.

Salary Range

$28.96 - $37.65/hourly

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.

An excellent fringe benefit package accompanies the salary, which includes:

• Medical, Dental, Vision, Life, Long Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility

Education

• Bachelors or better in Human Services

Licenses & Certifications

• Driver License

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.