The Tribal Option Specialty Team Care Manager will be responsible for providing proactive intervention and care coordination to members who are eligible for Tribal Option to ensure that these individuals receive the appropriate assessment and services. The Tribal Option Specialty Team Care Manager will be assigned to one of the three Tribal Option Specialty Teams. The three Tribal Option Specialty teams are I/DD/TBI/LTSS, Adults and Children with Special Health Care Needs, and Children and Families served by the child welfare system.

The Care Manager will work with members and the care team to alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, and coordination of services needed by the member across the Mental Health (MH), Substance Use (SU), intellectual/developmental disability (I/DD), traumatic brain injury (TBI), Children and Families served by the child welfare system, and unmet health-related resource needs networks. The Care Manager will seek to improve members near and long-term physical and behavioral health outcomes.

The Care Manager will be primarily responsible for assisting the member develop their care plan/ISP based on the needs and desires of the member/legally responsible person, team and their support system. Plans will be person centered in nature and reflect all the areas of support needed by the member. The Care Manager will ensure all level of care assessments are completed and is responsible for coordinating the member’s whole person care (Physical, Behavioral, pharmacy, BH, LTSS, IDD, TBI, and Unmet Social or Health-Related Resource Needs, including but not limited to vocational, education, social supports, personal safety, housing and food insecurity).

The Care Manager will coordinate care and facilitate seamless transitions for members who experience changes in treatment settings, child welfare placements, transitions to adulthood, and/or loss of Medicaid eligibility. The Care Manager will improve coordination with county DSS agencies, EBCI Family Safety program and more broadly, with Community Collaboratives – a comprehensive network of community-based services and supports leveraging a system of care approach to meet the needs of families who are involved with multiple child service agencies.

The Care Manager will 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.

The overall goal of the Care Management model is improved health outcomes for eligible individuals. The design of the model has been shaped by the following guiding principles:

• Broad access to care management. Care Management is available to all eligible individuals continuously, with limited exceptions.
• Dedicated care manager taking an integrated, whole-person approach. To the maximum extent possible, each enrolled individual will receive integrated, whole-person care management from a dedicated care manager with expertise and training in addressing behavioral health, I/DD, LTSS and/or TBI needs in addition to physical health needs and unmet health-related resource needs.
• Person and family-centered planning. Care planning for individuals will be person-centered and will consider their unique needs. Parents, other family members, and caregivers can also serve as part of the individual’s care team, with the individual’s consent. Tribal Option Care Management aligns with the North Carolina System of Care framework.

• Utilizes best practice models to identify, incorporate or develop best practices for panel management.
• Collaborates with other teams to share and establish best practice for health promotion and disease prevention strategies.
• Manages assigned panel by addressing and resolving acute care needs and chronic care needs through a team-based approach.
• Utilizes the electronic health record to assist with tracking and monitoring the appropriate follow-up of members targeting specific health indicators.
• Utilizes the care management platform for documentation of care management functions such as a care needs screening, comprehensive assessment, and care planning.
• Utilizes different available platforms/dashboards for population health and related interventions and innovations for management of care needs or gaps in care
• Utilizes NC Health connects for information gathering and data collections for management of care needs or gaps in care
• Coordinates and follows up on referrals to outside specialty providers, recent ED visits, and ICC visits.
• Coordinates and follows up on recent admissions and discharges.
• Provides member education, advice and information on health assessment, disease processes, medications, treatment plans and available community resources.
• Assesses member needs using established clinical guidelines, protocols, and pathways.
• Collects data from relevant sources (member, family, or caregiver) regarding the biological, psychological, social and cultural factors that might influence and impact the health status of the individual and utilizes this data in member center care plan development.
• Interprets data and recognizes existing relationships between data collected and the member’s health status and treatment regimen and determines the member’s need for immediate interventions.
• Initiates individualized care plan based on assessment of the member for specific illnesses, injuries, and diseases Social Determinants of Health (SDoH) and human behavior while adhering to appropriate standards of care.
• Develops individualized plan of care with input from the member, the member’s family, pod members, and anyone else the member requests to be included for those members considered “high risk.”
• Develops expected member outcomes that are observable and within an adequate period, and are congruent with the member’s present and potential physical capabilities and behavioral patterns.
• Responsible for assisting with establishing a multidisciplinary care team for each member.
• Coordinates closely with each member’s primary care provider (PCP), and, as appropriate, care manager extenders, assigned County Child Welfare worker, EBCI Family Safety Program staff, CIHA Care Team, family members and guardians to manage the member’s health care needs.
• Assumes coordination responsibility for transition planning.
• The care manager will make best efforts to contact the member during their stay in an inpatient psychiatric unit or hospital, Facility-Based Crisis, general hospital unit, or nursing facility and make best effort to contact the member on the day of discharge.
• Provides transitional care management during care transitions (including assisting individuals with transitioning from congregate or other intensive treatment settings to a foster care home or other community placement).
• Obtain a copy of the discharge plan for members being discharged from an inpatient psychiatric unit or hospital, Facility-Based Crisis, or general hospital unit, or nursing facility and review the discharge plan with the member and facility staff.
• Facilitate clinical handoffs.
• Responsible for ensuring members receive robust medication reconciliation and management.
• Assists the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management, and support medication adherence
• Directs the extender’s care management functions and ensure that the extender supports allowable activities (e.g., coordinating services/appointments by arranging transportation, etc.).
• Responsible for implementing the Healthy Opportunities Pilot (HOP) program for its HOP-eligible members
• Facilitates additional requirements for members obtaining 1915(i) services
• Duties specifically related to members who are CFSP:
• May be required to provide 24/7 support during emergencies or behavioral health crises, including working with County Child Welfare workers (or EBCI Family Safety Program staff) to secure immediate treatment services, as needed.
• Responsible for convening the care team on a regular basis (no less than twice per year, and more often, as appropriate) and sharing the care plan/ISP with the member’s care team and other representatives, as appropriate, to support delivery of the member’s needed health and health-related services.
• Required to coordinate closely with each member’s assigned County Child Welfare worker to share relevant health and health-related information
• Collaborate with County Child Welfare workers as needed in the development of the NCDSS-required transitional living plan and 90-day transition plan.
• Responsibility of the six core Health Home Services for the tailored plan
• Duties specifically related to I/DD, TBI, and LTSS:
• Obtain releases/documentation and provide to all stakeholders involved.
• Obtain clinical supporting documentation, legal/guardianship verification, and necessary consents to exchange/release information
• Ensure that service orders/doctor’s orders are obtained, as applicable
• Verify ongoing service adherence with member and/or guardian
• Monitor ISP implementation and resolve or escalate issues as needed
• Monitor members at least quarterly to ensure that any restrictive interventions (including protective devices used for behavioral support) are written into the Care Plan/ISP and the Positive Behavior Support Plan;
• Monitor for HCBS compliance
• Notify Tailored Plan/LME/MCO of updates to eligibility and/or need for 1915(i) 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.
• Escalate complex cases and cases of concern to the Supervisor.
• Participate and complete all required agency trainings and meetings, as well as all required care management-based trainings from the State, Technical Assistance entity or payor and within required timeframes as assigned.
• Travel to various community locations, other agencies and other outreach destinations as necessary to meet the members’ needs.
• Maintain all certification(s) or licensure required for the position.
• Demonstrate awareness and knowledge of and comply with all agency policies and procedures, as well as state and federal statutes and regulations related to care management.
• Meet at least minimum standards of monthly contacts and demonstrate ability to effectively engage with members.
• Participate in agency’s twenty-four (24) hour coverage around care management providing for coverage for services, consultation or referral as needed and arrange treatment for emergency medical conditions including behavioral health crises. Specifically, coverage will include the ability to share information such as care plans and psychiatric advance directives and coordinate care to place the member in appropriate setting during urgent and emergent events.
• May be subject to on-call and callback.
• May be necessary to work when administrative leave is granted if member care would be compromised.
• The incumbent will be evaluated annually on his/her ability to identify, assess, analyze, and evaluate data and solve problems through the CIH Performance Appraisal System.

Care Managers serving all members must have the following minimum qualifications:

• Meet North Carolina’s definition of a Qualified Health Professionalper 10A-NCAC 27G. 0104
  1. "Qualified professional" means within the mh/dd/sas system of care either:

1. 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 serv
2. 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;
3. 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
4. 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.

• For care managers serving members with LTSS needs: two years of prior LTSS and/or HCBS coordination, care delivery monitoring and care management experience, in addition to the requirements cited above. (This experience may be concurrent with the two years of experience working directly with individuals with behavioral health conditions, and I/DD or TBI conditions above).
• AND in addition to the conditions above
• Specific experience working with Native Americans preferred.
• Current Basic Life Support (BLS) minimally required. Can be acquired through the facility within 6 months following appointment to position.
• Applicant must have a valid North Carolina driver’s license.

• Knowledge and ability to independently plan, manage, and organize work in order to meet priorities, accomplish work within established time frames and work in stressful situations.
• Knowledge of the occupational functions of multi-disciplinary health care team.
• Knowledge of the culture and medical health profile of the member population.
• Knowledge and ability to teach and counsel member/family on health maintenance and disease prevention.
• Knowledge of available health care programs and community resources.
• Knowledge of care management including screenings, assessments, development of care plans and knowledge of resources available to members at all levels including tribal, county, regional and state.

• Knowledge of LOC process, SIS for IDD and FASN assessment for TBI
• Knowledge of Medicaid basic, enhanced MH/SUD, and waiver benefits plans
• Knowledge of and skilled in the use of motivational interviewing and techniques
• Strong interpersonal and written/verbal communication skills
• Conflict management and resolution skills
• Proficient in Microsoft Office products (such as Word, Excel, Outlook, etc.)
• Ability to master care management platforms and review data for decision making and person-centered planning
• 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

• Good organizational skills to prioritize duties and work with minimal levels of onsite supervision to consistently meet deadlines
• In addition, have a working knowledge of the special needs of members who fall into the category of being eligible for Tailored Care Management services which includes those members with care needs related to a behavioral health condition (including both mental health and substance use disorders), intellectual/developmental disability (I/DD), or traumatic brain injury (TBI).
• Expertise in the systems and tools that are fundamental to the transition to adulthood, including independent living skills (e.g., accessing food and transportation), post-high school education, housing and employment options, self-advocacy, health insurance coverage options after Medicaid eligibility ends and building natural supports.

Complexity of Duties

Complies also with federal, state, accrediting and local regulations. These guidelines are not always specifically applicable to the individual member or situation and independent judgment is required in selecting the most appropriate guideline, and applying the intent of the guideline to the specific situation at hand.

Supervision Received

The incumbent independently plans, schedules, and provides care in coordination with the medical care plan and Tribal Option Care plan and attempts to solve problems only within established procedures. This is done under the supervision of the Tribal Option Specialty Team Care Manager Supervisor, the Tribal Option Care Manager Supervisor, the Assistant Director of Care Management, and the Director of Care Management. The work is evaluated for technical soundness and adherence to professional standards.

Responsibility for Accuracy

Contacts with Others

Contacts are with members, families, hospital personnel, and community agencies. Contacts with members, families, and hospital personnel are to exchange, provide, and obtain information concerning the member’s physical and psychosocial health care problems, and needs. The nurse uses teaching and counseling methods to influence and motivate member and family behavior. Contacts with other health care or related disciplines within the hospital are for the purpose of collaboration and consultation. Tact, courtesy, and professional conduct are required to maintain positive working relationships. Utmost sensitivity and confidentiality is required when dealing with members and families.

Confidential Data

The incumbent has access to highly confidential member medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and all other pertinent information that comes to his/her attention or knowledge. The Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action.

Mental/ Visual/ Physical

Work in the various services within the Primary Care department is mostly sedentary, yet requires walking, standing, bending, pushing, and lifting in helping members to and from beds, wheelchairs, and stretchers. These same activities are required in moving equipment and medical supplies. Will be subject to frequent interruptions requiring varied responses, which can cause distractions therefore, the incumbent must possess the ability to differentiate and prioritize many tasks at once.

Environment

Must be flexible in working hours. This position offers a hybrid work model, with the flexibility to work remotely or from the designated work space. Specific workdays and location will be determined in collaboration with the team, the Tribal Option Care Manager Specialty Lead, and Tribal Option Care Manager Supervisor. The incumbent may occasionally be required to perform care management duties and tasks within the clinical setting. incumbent is required to comply with Employee Health Program guidelines including current immunization status of identified communicable diseases and safety precautions are sometimes necessary, such as use of personal protective equipment as required by hospital policy. The work environment involves moderate risks of exposure to infectious disease, radiation, electrical hazards, irritant chemicals and explosive gases. Some travel is required. Infrequent overnight travel may be required for meetings or to attend training.

Customer Service

Consistently demonstrates superior customer service skills to members/customers by demonstrating characteristics that align with CIHA’s guiding principles and core values. Ensure excellent customer service is provided to all members/customers by seeking out opportunities to be of service.