MHSU DSS Embedded Care Manager - TP
Company: Vaya Health
Posted on: March 17, 2023
LOCATION: Remote - Chatham County GENERAL STATEMENT OF JOBThe MHSU
Care Manager (CM)- DSS, hereafter referred to as DSS CM, is a
unique position within the Mental Health/Substance Use (MHSU) Care
Management Team who is co-located at our local Department of Social
Services (DSS). This positions is responsible for all the MHSU Care
Manager aspects as well as consultation, education, focused
communication, and system navigation for DSS social workers.
Provides proactive intervention and coordination of care to
eligible members identified as Special Health Care Needs, Complex
Care Management or High-Risk High Cost populations to ensure that
these individuals receive appropriate assessment and services, with
a focus on those members and families involved with DSS. Works with
the member and care team to alleviate inappropriate levels of care
or care gaps through assessment, 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. Supports clinical transition planning assistance to
local hospitals and tracks individuals discharged from state and
community hospitals to ensure they follow up with aftercare
services and receive needed assistance to prevent further
hospitalization. Point of contact for supporting DSS emergency
placement issues. This is a mobile position with work done in a
variety of locations but primarily co-located with the local
Department of Social Services and in memebers home communities.
Essential job functions of the MHSU Care Managers include, but may
not be limited to:
- CM Platform basics
- Outreach & Engagement
- Release of Information practices
- Health Risk Assessment
- Medication List and Continuity of Care process
- Care Planning
- Interdisciplinary Care Team and Ongoing Care Management
- Consultation with DSS
- Education and System Navigation with DSS ESSENTIAL JOB
FUNCTIONSConsultation, Collaboration, System Navigation
- Coordinate and facilitate a shared case staffing with DSS
social workers, behavioral health providers and Vaya care
management in order to proactively plan for and communicate care
- Provide clinical and administrative consultation for DSS social
- Provide system navigation for DSS social workers to understand
and work within the behavioral health system. Participate in DSS
facilitied staffings to provide consultation and support.
- Serve as a collaborative partner in identifying system barriers
through work with community stakeholders.
- Manage and facilitate Child/Adult Team meetings in
collaboration with DSS, DJJ, CCNC, school systems, and other
community stakeholders as appropriate.
- Partner with other Vaya departments to address identified needs
within the catchment.
- DSS CM may participate in cross-functional clinical and
non-clinical meetings and other projects to support the department
- Participate in routine multidisciplinary huddles including RN,
Pharmacist, M.D. to present complex clinical case presentation and
needs, providing support to other CCM's and receiving support and
feedback regarding CM interventions for clients' medical,
behavioral health, intellectual /developmental disability,
medication, and other needs.
- Participate in other high risk multidisciplinary complex case
staffing's as needed to include Vaya Chief Medical Officer, Deputy
Chief Medical Officer, 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. Clinical Assessment:
- Meets with members to conduct a comprehensive bio-psycho-social
assessment in order to gather information on their overall health,
including behavioral health, developmental, medical, and social
- Administer the PHQ-9, GAD, CRAFFT, ACES, LOCUS/ CALOCUS, and
other assessments based on member's clinical needs and scores are
calculated and reviewed allowing CM to provide specific education
and self-management strategies as well as linkage to appropriate
- Review and transcribe member's current medication and entering
into Vaya's Care Management platform to ensure the medication
aspects of the members health and care are addressed according to
- Ensure members of the care team are involved in the assessment
as indicated by the member and other available clinical information
is reviewed and incorporated into the assessment.
- Review clinical assessments conducted by providers to ensure
all areas of the member's needs are addressed. Care Planning &
Interdisciplinary Care Team
- Create a person-centered care plan for members to help define
what is important to members for their health.
- Assist members in refining and formulating treatment goals,
identifying interventions, measurements, and barriers to the
- Partner with the integrated care team (i.e. RN and pharmacist)
along with the member to address needs and goals in the most
effective way and monitor progress.
- Ensure Care Plans include specific services to address mental
health, substance use or intellectual/developmental disability,
medical and social needs as well as personal goals.
- Ensure care plans are developed at least once a year or anytime
there is a significant life change.
- Ensure members/guardians have the opportunity to decide who
they want at the care team meeting and coordinates and may
facilitate the team meeting where member Care Plan is discussed and
- Ensure the assessment, care plan and other relevant information
is provided to the care team as indicated in Vaya policy.
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
OR, a combination of education and experience as follows:Meet North
Carolina's Qualified Professional Definition: an RN licensed to
practice in North Carolina who has four years of full-time
accumulated experience in MH/DD/SAS with the population served; or
Bachelor's degree in a field other than human services and has four
years of full-time, post-bachelor's degree accumulated MH/DD/SAS
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; or a Masters degree in a human service field and
has one year of full-time, post-graduate degree accumulated
MH/DD/SAS experience with the population served.
Licensure/Certification Required:*If RN, must be licensed in North
Carolina. PHYSICAL REQUIREMENTS:
- Close visual acuity to perform activities such as preparation
and analysis of documents; viewing a computer terminal; and
- 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.
KNOWLEDGE, SKILL & ABILITIES:
- Familiar with Department of Social Services regulations and
- Participate in and maintain Care Management and Vaya trainings
and proficiencies as required.
- A high level of diplomacy and discretion to effectively
negotiate and resolve issues with minimal assistance.
- 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.
- Highly skilled at shifting between macro and micro level
planning, maintaining both the big picture and seeing that the
details are covered.
- Extensive understanding of the Diagnostic and Statistical
Manual of Mental Disorders (current version)
- Knowledge of the MH/SU/DD service array provided through the
network of Vaya providers.
- Knowledge in Vaya Medicaid B and C waivers and accreditation is
- Detail oriented, able to organize multiple tasks and
priorities, and to effectively manage projects through
- Ability to change the focus to meet changing priorities.
- Exceptional communication skills, peer partnership, making
appropriate decisions in high stress situations, being polite,
respectful and assertive while maintaining positive
- Knowledge of standard office practices, procedures, equipment
and techniques and have intermediate to advanced proficiency in
Microsoft office products (Word, Excel, Power Point, Outlook,
- Understand the following areas, in addition to other required
- BH I/DD Tailored Plan eligibility and services
- Whole-person health and unmet resource needs (ACEs, Trauma,
- 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
- 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,
- Serving children (Child- and family-centered teams,
Understanding of the "System of Care" approach)
- Serving pregnant and postpartum women with SUD or with SUD
- Serving members with LTSS needs (Coordinating with supported
employment resources RESIDENCY REQUIREMENT: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 exempt and is not eligible for overtime
DEADLINE FOR APPLICATION: Open Until Filled
APPLY: Vaya Health accepts online applications in our Career
Center, please visit https://www.vayahealth.com/about/careers/.
Vaya Health is an equal opportunity employer.
Keywords: Vaya Health, Durham , MHSU DSS Embedded Care Manager - TP, Executive , Pittsboro, North Carolina
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