Care Manager I-Waiver (Full-time Remote, North Carolina Based)

The Care Manager l - Waiver assures that individuals and families with special health care needs receive integrated whole-person-person centered 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 focus on a specified population of members utilizing health care services while ensuring all member health needs and referrals are addressed. The Care Manager l will collaborate with other community systems to work in partnership to support the identified population. This position is full time 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 Complete required Screening Tools Retrieve and review historical data to better-understand member’s treatment history Submit referrals to the Transition Coordinator 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 (LRP) 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 collaborates 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 including collaborating with residential placement search in conjunction with internal team members or external stakeholders as needed Submits required documentation to UM to ensure timely delivery of services - and trouble shoot until authorization is obtained. Notify a member’s care team and providers of successful authorization (for residential or waiver related services) For Medicaid C, enlist administrative support to send Level of Care (LOC) and initial Individual Service Plan (ISP) to Department of Social Services (DSS) to turn on special waiver program indicator. Verify that necessary Client, Employer, Group (CEG) enrollments are correct in JIVA, and that Medicaid eligibility is updated in Alliance Claims System Provide Support and Monitoring to Members Schedule initial contact with member for purpose of assessment and engagement Verify accuracy of demographic information with member. Update inaccurate information from the Global Eligibility File following documented protocols 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 that no new clinical needs warrant a change in condition assessment 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 Coordinate and participate with SIS Team to ensure successful completion of SIS assessment within time frames allotted For facility (ICF, Hospital, PRTF or SDC) discharges, inform SIS Supervisor that an assessment needs to be scheduled Schedule and facilitate the ISP meeting, develop and update ISP Submit requests for services and purchase orders for products, supplies, and services covered under the