Job description

SUMMARY

An I/DD TCM Care Manager will be responsible for addressing members’ whole-person needs alongside coordinating and monitoring their Home and Community Based (HCBS) waiver services. TCM Care Manager will focus on a full range of the following needs of the consumer: physical health, I/DD, TBI, LTSS, pharmacy and unmet health-related resource needs Services will be provided at the site of care, in the home or in the community, through face-to-face interaction between consumers, providers, and care managers. Care management will promote whole-person care, foster high functioning integrated care teams, and drive towards better health outcomes. This position requires an understanding of and experience working with individuals who are impacted by Intellectual Developmental Disabilities (I/DD) or Traumatic Brain Injury (TBI).

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following, but not limited to:

• Facilitate provider choice and assignment process for Innovations and TBI waiver enrollees.
• Responsible for creating initial care management comprehensive assessment within 45-90 days based on member’s and conducting reassessments at least annually, and more often as needed.
• Ensure care management comprehensive assessment results are shared with the member’s care team within 14 days of completion.
• Responsible for creating initial Tailored Care Management Individual Support Plans (ISP) within 30 days of completion of the care management comprehensive assessment.
• Responsible for completing updates to the ISPs upon the following: at minimum every 12 months; when the member’s circumstances or needs change significantly; at the member’s request; within 30 days of care management comprehensive (re)assessment; and/or after triggering events.
• Maintain a caseload ratio of an average of the following depending on acuity level: High – 29:1, Medium – 46:1, Low – 142:1
• Conduct required contacts with members, based on acuity level:

High – At least (3) care manager-to-member contacts per month, including at least (2) in-person contacts with the member, Moderate – At least (3) care manager-to-member contacts per month and at least (1) in-person contact with the member quarterly, Low – At least (1) care manager-to-member contact per month and at least (2) in-person contacts per year, approximately 6 months apart

(includes care management comprehensive assessment if it was conducted in-person)

• Ability to modify ISPs with input from recipient, professionals, and natural supports.
• Engage other professionals and natural supports in the (re)assessment process.
• Recognize indicators of risk including health, safety, physical, medications, etc.
• Discuss findings and recommendations with the consumer in a clear and understandable manner.
• Engage clinical consultants as needed so they may provide subject matter expert advice to the care team.
• Locating and coordinating sources of help so that the individual receives available natural and community supports.
• Apply appropriate interventions for assessed needs.
• Facilitate the multidisciplinary care team meetings.
• Ability to research, develop, maintain, and share information on community-based and other unmet health-related resources relevant to the consumer’s needs (medical & behavioral health programs, formal/informal supports, social service, educational, employment, housing)
• Facilitating the recipient’s transition into services in the ISP to achieve the outcomes derived for the consumer’s goals.
• Understand values that underlie a person-centered approach to providing service to improve the consumers functioning within the context of the consumers culture & community.
• Perform work in a range of community settings such as recipient’s home, school, library, homeless shelters, etc.
• Provide or arrange for coverage for services, consultation or referral, and treatment for emergency medical conditions, including behavioral health crisis, 24 hours per day, seven days per week.
• Ensure that the member has an annual physical exam or well-child visit, based on the appropriate age-related frequency.
• Must conduct continuous monitoring of progress toward goals identified in the ISP through face-to-face and collateral contacts with the member and his or her support member(s) and routine care team reviews.
• Support the consumer’s adherence to prescribed treatment regimens and wellness activities.
• Provide education to the consumer in self-management, education and guidance on self-advocacy to consumer, family members and support consumers.
• Provide guidance and support for prenatal needs.
• Follow-up on referrals for care.
• Coordinate information and resources for self-directed services for Innovation’s waiver.
• Assist with scheduling of appointments, including arranging transportation.
• Provide information to the member, family members, and support members about the member’s rights, protections, and responsibilities, including the right to change providers, the grievance and complaint resolution process, and fair hearing processes.
• Provide information on establishing advance directives, including psychiatric advance directives as appropriate, and guardianship options/alternatives, as appropriate.
• Manage care transitions for members transitioning from one setting to another.
• Maintains accurate and legible documentation, as required.
• Flexible and ability to adapt to any occurring changes.
• Maintain a good working relationship with family and consumer.
• Coordinate absences from work in a timely manner.
• Fulfill all other duties assigned.

EDUCATION/QUALIFICATION REQUIREMENTS

• A bachelor’s degree in a field related to health, psychology, sociology, social work, nursing, or another relevant human services area, or licensure as a registered nurse (RN); and
• Two years of experience working directly with individuals with an I/DD or a TBI; and
• For care managers serving dually-diagnosed members with a behavioral health condition and an I/DD or a TBI, they must demonstrate two years of experience working directly with both populations; and
• 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 I/DD, or a TBI, above.)

Job Type: Full-time

Pay: $55,000.00 - $65,000.00 per year

Benefits:

• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Supplemental pay types:

• Bonus pay
• Signing bonus

Education:

• Bachelor's (Preferred)

Experience:

• Case management: 2 years (Preferred)
• I/DD: 2 years (Preferred)
• Behavioral health: 1 year (Preferred)

Work Location: Hybrid remote in Tarboro, NC 27886

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