Acute Transitional Care Manager (Durham, NC)
Company: Vaya Health
Location: Asheville
Posted on: April 18, 2024
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Job Description:
LOCATION: Remote - must reside within 1 hour of Durham, NC.
GENERAL STATEMENT OF JOB:The Acute Transitional Care Manager (ATCM)
is responsible for proactive intervention and coordination of care
to members and recipients of Vaya's Health plan who are receiving
care in an inpatient community hospital or Emergency Department in
some instances who require complex care planning to alleviate
inappropriate levels of care or care gaps through multidisciplinary
team care planning, linkage and/or coordination of services across
the MH/SU/IDD and other healthcare network(s) with existing or new
care team members within the Acute Transitional CM professional
scope. The ATCM is responsible for knowing and implementing
organizational policies, Division and departmental specific
guidelines.Activities may include but not limited to the following:
In cooperation with community hospital discharge planning teams,
participate in developing transition plans, educating staff and
members regarding network services and supports with consideration
of medical necessity, funding eligibility and appropriateness of
recommendations relative to person centered, recovery principles
and known best/appropriate practice. Develop, coordinate and link
emergency discharge services (up to and including residential
placement based on medical necessity, funding and service
definitions or EPSDT for children/youth) for members who are
inappropriately discharged from residential facilities (child or
adult); coordination with Vaya's FastTrack process; notifying Vaya
Health Network of provider contractual concerns or through
established process if quality of care or health and safety
concerns; Notification and update of assigned community-based Care
Manager (CM) and care team if member is currently
assigned.Coordination and consultation with Vaya RN CM for
transition management support.Transition to community-based CM post
discharge.Participate in the development and implementation of best
practice complex care strategies as identified by Vaya Health.
Provide proactive and clear supervision supported by data to ensure
supervisors and teams are meeting departmental and organizational
benchmarks; and Collaborate with key stakeholders, network
providers and non-network providers with particular attention to
crisis, inpatient, 3-way bed contracts, NC START, etc.Engage and
develop collaborative relationships with members using our
Transitional Care Management and Tailored Care Management
staff-such as our Care Managers and Peer Support Specialists-that
use motivational interviewing techniques to understand the root
causes that lead to exacerbation of symptoms and the use of
emergency services or inpatient admissions Address Unmet
Health-Related Resource Needs that may be barriers to care or
impacting the health of membersUtilize ADT feeds and alerts to
ensure prompt, efficient coordination and support This position
works with staff, community partners and members in Vaya Health
catchment.
ESSENTIAL JOB FUNCTIONS:Acute Assessment, Care & Transition
Planning & Interdisciplinary Care Team:Conduct or ensure all
elements of transitional care management are implemented for
members during inpatient stay to include, but are not limited to
the following:Proactively ensures that members assigned to Vaya CM
have a CM assigned to manage the transition Links members, at a
minimum, to primary care and behavioral health care.Ensures that
the care plan includes a transition plan and ensure it is developed
by care team or, if necessary, by the ATCM to meet needs and to
access care for the individual.Convenes key providers and others to
address needs of the individual, ideally in person or
telephonically while member is still in facility.Visit the member
during their stay in hospital and be, or be sure a member of the
care team, is present on the day of discharge.Identifies gaps in
services and supports, intervenes to ensure that the member
receives and can access appropriate care.Measures results of
intervention and treatment, including reduction a high-risk events
and inappropriate service utilization.Ensures that services are
coordinated across the Vaya Health system and with other systems,
including primary care and Opportunities for Health services and
supports.Provides clinical transition planning assistance to local
community hospitals, and coordinates with care team, and tracks
those discharged from local hospitals to ensure they follow up with
aftercare services and receive needed assistance to prevent further
hospitalizations.Assist the member in obtaining needed medications
prior to discharge, ensure an appropriate care team member conducts
medication reconciliation/management and support medication
adherence.Develop or begin development of a ninety (90) day
post-discharge transition plan prior to discharge from inpatient
settings, in consultation with the member, facility staff and the
member's care team, that outlines how the member will maintain or
access needed services and supports, transition to the new care
setting, and integrate into their community.89/*kio8
Essential job functions of the ATCM include, but may not be limited
to: CM Platform basicsOutreach & EngagementRelease of Information
practicesHealth Risk Assessment Medication List and Continuity of
Care processCare PlanningInterdisciplinary Care Team and Ongoing
Care Management
Collaboration:This position will interface with key stakeholders
and is responsible for understanding Vaya Health organizational
goals, initiatives and requirements in order to effectively
communicate and facilitate collaborative partnerships. This
position is also expected to provide information from key
stakeholder interactions to the appropriate departments and teams
to improve the care continuum for members. Serve as a collaborative
partner in identifying system barriers through work with community
stakeholders, manages and facilitates care teams as
appropriate.
ATCM may participate in cross-functional clinical and non-clinical
meetings and other projects to support the department and
organization. Participate in routine multidisciplinary huddles
including RN, Pharmacist, M.D. to present complex clinical case
presentation and needs, providing support to other CM's and
receiving support and feedback regarding CM interventions for
clients' medical, behavioral health, intellectual /developmental
disability, medication, and other needs. ATCM participates and
ensures staff participate in other high risk multidisciplinary
complex case staffing as needed to include Vaya Medical Director,
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.
Other duties as assigned.
KNOWLEDGE OF JOB:Participate in and maintain Care Management and
Vaya trainings and proficiencies as required. A high level of
diplomacy and discretion is required to effectively negotiate and
resolve issues with minimal assistance.Interpersonal skills, highly
effective communication ability, and the propensity to make prompt
independent decisions based upon relevant facts.Problem solving,
negotiation, arbitration and conflict resolution skills are
essential to balance the needs of both co-workers and
consumers/enrollees.Highly skilled between macro- and micro-level
planning, maintaining a system and individual perspective.
Understanding of the Diagnostic and Statistical Manual of Mental
Disorders (current version) Knowledge of the MH/SU/IDD service
array provided through the network of Vaya Health providers,
Population Management, Disease Management and Risk Management
principles and strategies.Knowledge in Vaya Health Medicaid B and C
waivers, working knowledge state plan Medicaid and Medicare
services, Vaya Health state funded initiatives and services,
integrated care and accreditation is essential.Detail oriented,
able to organize multiple tasks and priorities, and to effectively
manage projects from start to finish.Work activities quickly change
according to mandated changes and changing priorities within the
department. The employee must be able to change the focus of
his/her activities to meet changing priorities.Knowledge of
standard office practices, procedures, equipment, and techniques
and have intermediate to advanced proficiency in Microsoft office
products (Word, Excel, Power Point, Outlook, Teams, etc.)
Training, learning and proficiency are tracked through the Care
Management Training Matrix and any other required means. Training
may be delivered in a variety of methods and forums. Understand the
following areas, in addition to other required trainings: BH I/DD
Tailored Plan eligibility and services Whole-person health and
unmet resource needs (ACEs, 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 SUD or with SUD
history Serving members with LTSS needs (Coordinating with
supported employment resources
QUALIFICATIONS & CREDENTIALING REQUIREMENTS: Bachelor's degree in a
Human Services field such as social work, counseling, or psychology
and 2 years of experience working with the identified
population.
LICENSURE/CERTIFICATION REQUIREMENTS:N/A
PHYSICAL REQUIREMENTS: Close 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.
RESIDENCY REQUIREMENTS:The person in this position is required to
reside in North Carolina or within 40 miles of the NC border.
SALARY: Depending on qualifications & experience of candidate. This
position is exempt and is not 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, Asheville , Acute Transitional Care Manager (Durham, NC), Executive , Asheville, North Carolina
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