Complex Care Coordinator (Multiple Counties, NC)

Company: Vaya Health
Location: Hayesville
Posted on: March 12, 2025

Job Description:

LOCATION: Remote - must live in or near Jackson, Swain, Graham, Macon, Cherokee, or Clay County, North Carolina. The position must live in North Carolina or within 40 miles of the NC border.

GENERAL STATEMENT OF JOBComplex Care Coordinator (CCC) is responsible for knowing and implementing North Carolina Department of Health and Human Services standards and organizational policies. CCC proactively intervenes and coordinates care for Medicaid members not eligible for Tailored Care Management and who have complex care coordination needs. Those include members having Behavioral Health Transitional Care Needs; Special Health Care Needs related to Behavioral Health, Intellectual/Development Disabilities (I/DD), TBI, ; Members Obtaining Care Management, Care Coordination or Case Management through Another Entity and Not Engaged in TCM (i.e. Primary Care Case Management (PCCM), Community Alternatives Program for Disabled Adults (CAP C/DA), Tailored Care Management Duplicative Services, Children's Developmental Services Agencies (CDSA), Indian Health Services). CCC works with Vaya staff, care teams, providers, community stakeholders, and members and family members to alleviate inappropriate levels of care or care gaps, coordinate multidisciplinary team care planning, linkage and/or coordination of services across the MH/SU/IDD and other healthcare network(s). CCC also provides administrative transition planning assistance to local hospitals and other institutions. This is a mobile position with work done in a variety of locations [i.e., member's home community, provider office(s), remote]. Essential job functions 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 ManagementTransitional Care ManagementDiversion *Must reside in North Carolina ESSENTIAL JOB FUNCTIONSClinical Assessment, Care Planning & Interdisciplinary Care Team:Complex Care Coordination for Members with a BH Transitional Care NeedOversee Care Transitions for eligible membersIdentify eligible members using ADT feed, PCCM platform, hospital relationships, internal reports.Conduct Transitional Care Assessment (prior to discharge if possible) and share with member providers.Develop 90-day transition plan (prior to discharge if possible) and share with member providers. Conduct transitional care management functions including:Ensure that a care manager is assigned to manage the transition.Have a care manager assume coordination responsibility for transition planning. Have a care manager visit the member during their stay in an inpatient psychiatric unit or hospital, Facility-Based Crisis, general hospital unit, or nursing facility and be present on the day of discharge.Conduct outreach to the Member's Providers.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.Refer and assist members in accessing needed social services and supports identified as part of the care coordination process, including access to housing. Assist with scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven (7) Calendar Days post-discharge or use of a crisis service, unless required within a shorter timeframe.Ensure that the assigned care manager follows up with the Member within forty-eight (48) hours of discharge or use of a crisis service, to the maximum extent possible. Arrange to visit the Member in the new care setting after discharge/transition.Complex Care Coordination for Members with Special Health Care Needs Related to BH, I/DD, TBI and Not Engaged in TCMAssess member needs related to any condition that require a course of treatment or regular care monitoring Develop engagement strategies, including identifying barriers to treatment and referral. Connect members with services identified through assessmentCreate Care Plan and share with member and care teamCoordination with Primary Care Case ManagementCCC is the lead for BH transitional care need; PCCM is lead for all other members care needsCCC checks the PCCM CM Information System to determine PCCM involvementEncourage collaboration between primary care and BH providersMake referrals to PCCM for care coordination. Weekly conference with PCCM vendor to share info on identified high risk membersReceive and respond to inquiries from medical providers, PCCM, CAP C/DA, Department of Social Services (DSS), Department of Juvenile Justice or other care/case managers within 1-3 days.Participate in care team meetings. Coordination with PCCM for Members with BH Transitional Care NeedsNotify the PCCM Care Manager of the transition, engage them to assist with transition, development of 90-day transition plan (include identifying each Care Manager/CCC role in the plan)Share transition assessment and plan with PCCM Care ManagerDiscuss member in weekly conference during week of transition

• Coordination with CAP C/DA Waiver Case Management Entity
• Vaya CCC is lead for members who have a BH transitional need, otherwise CAP is lead
• For members with a BH, I/DD, TBI need, the CCC:
• Coordinates to ensure no duplication occurs
• Shares care plan with CAP, as applicable
• Receive and respond to inquiries from medical providers, PCCM, CAP C/DA, Department of Social Services (DSS), Department of Juvenile Justice or other care/case managers within 1-3 days.
• Participate in care team meetings
• Other Care Management Programs - High Fidelity (HiFi) Wrap Around, Members Receiving ACTT, ICF, Nursing Facility longer than 90 Days
• For members residing in nursing home for longer than 90 days and who have BH needs and who are not eligible for TCM, ensure Complex Care Coordination for those with BH Transitional Care Need
• Have an expedited process (1-3 days) to receive and respond to inquiries from medical providers, PCCM, CAP C/DA, Department of Social Services (DSS), Department of Juvenile Justice or other care/case managers.
• Participate in care team meetings
• Coordination with CDSA for Children with BH, I/DD needs, Not Engaged in TCM
• Facilitate info sharing between Vaya and CDSA
• Partner with CDSA to identify unmet health related resource needs and connect family to social and community services as needed
• Consult with CDSA as needed when supporting youth with Early Intervention needs.
• Receive and respond to inquiries from medical providers, PCCM, CAP C/DA, Department of Social Services (DSS), Department of Juvenile Justice or other care/case managers within 1-3 days.
• Participate in care team meetings Collaboration, Coordination, Documentation:
• May provide services in situations that require such as staff shortages or an elevated need for services. Serves as a collaborative partner in identifying system barriers through work with community stakeholders.
• Manages and facilitates Child/Adult High-Risk Team meetings in collaboration with DSS, DJJ, CCNC, school systems, and other community stakeholders as appropriate.
• Works in partnership with other Vaya departments to address identified needs within the catchment. CCC 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 CCCs and receiving support and feedback regarding Complex Care Coordination interventions for member medical, BH, I/DD, medication, and other needs.
• CCC participates in other high risk multidisciplinary complex case staffings 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 member needs within or outside the current behavioral health system.
• Ensure quality care, health/safety of the individual, as well as the continued appropriateness of services
• Monitor services for compliance with standards
• Promote problem-solving and goal-oriented partnership with member/guardian(s), providers, etc. and recognize and report critical incidents
• Promote satisfaction through ongoing communication and timely follow-up on any concerns/issues
• Educate members/families on services and resources.
• Verify member continuing eligibility for Medicaid
• Promptly follow-up on issues
• Proactively responds to a member's planned movement outside the Vaya's geographic area to ensure changes in their Medicaid County of eligibility are addressed prior to any loss of service
• Maintain electronic health record compliance/quality according to Vaya policy
• Proactively monitor own documentation to ensure that issues/errors are resolved as quickly as possible
• Ensure all clinical and non-clinical documentation (e.g., goals, plans, progress notes, etc.) meet state, agency and Medicaid requirements
• Participate in and maintain Care Management and Vaya trainings and proficiencies Other duties as assigned.
  KNOWLEDGE, SKILL & ABILITIESAbility to express ideas clearly/concisely
  Represent Vaya in a professional manner
  An ability to initiate and build relationships with people in an open, friendly, and accepting mannerAbility to take ownership of projects from planning through executionStrong attention to detail and superior organizational skillsAbility to multitask and prioritize to manage multiple projects on tight timelinesAbility to understand the strategic direction and goals of the department and support appropriate processes to facilitate achievement of business objectivesWell-developed capabilities in problem solving, negotiation, conflict resolution, and crafting efficient processesA result and success-oriented mentality, conveying a sense of urgency and driving issues to closureComfort with adapting and adjusting to multiple demands, shifting priorities, ambiguity, and rapid changeProficiency in Microsoft Office and Vaya systems, to include Excel, data analysis, and secondary researchDemonstrated knowledge of the assessment and treatment of developmental disabilities, without co-occurring mental illnessHave highly effective communication Knowledge in Vaya Medicaid B and C Waivers, NC Innovations Waiver, and accreditations and apply this knowledge in problem-solving and responding to questions/inquiriesHave a dynamic, proactive approach to assessment, screening, monitoring and coordination of care, to ensure quality supports and consistent adherence to waiver requirementsThis is a mobile position with work done in a variety of locations spending a considerable amount of time in the fieldEmployee will 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. This will require exceptional 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 internal and external customers. Must be highly skilled at shifting between macro and micro level planning, maintaining both the big picture and seeing that the details are covered.Complex Care Coordinator must exhibit an extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version) and have considerable knowledge of the MH/SU/DD service array provided through the network of Vaya providers. Additional knowledge in Vaya Medicaid B and C waivers and accreditation is essential.The employee must be 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.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. Complex Care Coordinator must understand the following areas, in addition to other required trainings:BH I/DD Tailored Plan eligibility and servicesWhole-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 historyServing members with LTSS needs (Coordinating with supported employment resources
• Complex Care Coordinator should be proficient in the aforementioned essential job functions. Job functions with higher consequences of error may be identified, and proficiency demonstrated and measured through job simulation exercises administered by the supervisor where a minimum threshold is required of the position.
• In addition, Complex Care Coordinator must have thorough 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) QUALIFICATIONS & EDUCATION REQUIREMENTSBachelor's degree in a field related to health, psychology, sociology, social work, nursing or another relevant human services area, and
• Two (2) years of experience working directly with individuals with BH conditions
• Two (2) years of experience working directly with individuals with I/DD or TBI
• Two (2) years of prior Long-tern Services and Supports and/or Home Community Based Services coordination, care delivery monitoring and care management experience. This experience may be concurrent with the two years of experience working directly with individuals with BH conditions, an I/DD, or a TBI, described above *Must meet the requirements of a North Carolina Qualified Professional per 10A NCAC 27G .0104 OR a combination of education and experience as follows:Must be a registered nurse who is licensed to practice in the State of North Carolina by the North Carolina Board of Nursing and must have four years of full-time accumulated experience in mh/dd/sa with the population served. If Bachelor's Degree in Field other than Human Services Degree: Four years of full-time, post-bachelor's degree accumulated MH/DD/SA experience with the population served, or a substance abuse professional who has four years of full-time, post-bachelor's degree accumulated supervised experience in alcoholism and drug abuse counseling. *If Master's Degree, although only one year of full-time, pre- or post-graduate degree accumulated supervised mh/dd/sa experience with the population served is required it is still a requirement of the role that an incumbent must have at least two years of experience **Full-time Mental Health/Developmental Disabilities/Substance Abuse Services experience required for credentialing as a Qualified Professional may be obtained before or after obtaining the educational degree. Licensure/Certification Required:*If RN, licensure as an North Carolina RN (see education section). PHYSICAL REQUIREMENTSClose 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 REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border. SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is 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, Cleveland , Complex Care Coordinator (Multiple Counties, NC), Other , Hayesville, Tennessee