CSFP Care Manager - $5,000 Hiring Bonus

Job Description

Job Description:\n\n Job Title: CSFP Care Manager Job Code: CSFP CM Department: Tribal Option/ Primary Care Division: Nursing/Tribal Option Salary Level: Non-Exempt 12 Reports to: CSFP Care Management Supervisor Last Revised: August 2024 Primary Function The CFSP(Children and Families Specialty Program) aims to improve the health and well-being of children, youth and families served by the child welfare system. The CFSP design emphasizes a family-focus and seeks to: • Improve members’ near- and long-term physical and behavioral health outcomes. • Increase timely access to physical health, behavioral health, pharmacy, LTSS and I/DD providers with experience serving children with high acuity needs, as well as unmet health-related resource needs. • Strengthen and preserve families, prevent entry and re-entry into foster care, and support reunification and other permanency plan options. • 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. • Improve coordination and collaboration 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. • Provide services that meet children’s behavioral health needs and prevent children from boarding in county DSS agency offices and Emergency Departments. For Members that have Tailored Care Plan eligibility, the incumbent is responsible for those aspects of care for that member. 2 Job Description • 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 panel by addressing and resolving acute care needs and chronic care needs through a team based approach. • Utilizes iCare to track, monitor, and assure the appropriate follow-up of clients targeting specific indicators. • Utilizes the care management platform for documentation of care management functions such as a care needs screening, Comprehensive assessment, and care planning. Also utilizes the dashboards, within the care management platform for population health and related interventions and innovations • 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. Emphasis is placed on ensuring treatment notes are available to the PCP timely. • Participates in the continued development of the role of Case Management in the Patient Centered Medical Home (PCMH) and Advanced Medical Home (AMH). • Promotes health care outcomes with currently accepted clinical practice guidelines. • Provides patient education, advice and information on health assessment, disease processes, medications, treatment plans and available community resources. • Assesses patient needs using established clinical guidelines, protocols, and pathways. • Provides appropriate follow up as directed or per established guidelines. • 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. • Collects data from relevant sources (patient, 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 patient center care plan development. • Collects data through observations of appearance and behavior, measurements of physical structure and physiological function, and other information in an effort to place consultations and/or referrals to the correct internal and external resources (Nutrition, Tsali Manor, etc.). • Interprets data and recognizes existing relationships between data collected and the client’s health status and treatment regimen and determines the client’s need for immediate nursing interventions. • Reviews the patient’s health records and health summary, interviewing patients and family members, documenting the chief complaints, medical history, physical and clinical findings, identifying learning needs of the patient and family, and determining priority of care required. Assessment for health prevention, health promotion, restorative, and health maintenance needs is emphasized. 3 • Will plan patient care according to individual assessed patient needs and established hospital policies and procedures. • Develops individualized plan of care with input from the patient, patient’s family, care team members, and anyone else the patient requests to be included for those patients considered “high risk.” • Initiates individualized care plan based on assessment of the patient for specific illnesses, injuries, and diseases Social Determinants of Health (SDoH) and human behavior while adhering to appropriate standards of care. • Develops expected patient outcomes that are observable and within an adequate period, and are congruent with the patient’s present and potential physical capabilities and behavioral patterns. • Assumes coordination responsibility for transition planning. o Use of ADT including high risk ADT Alerts: ▪ Real time (within minutes/hours) response to notifications of ED visits. ▪ Same-day or next-day outreach for designated high-risk subsets of the population; and ▪ Additional outreach within several days after the alert to address outpatient needs or prevent future problems for other patients who have been discharged from a hospital or an ED (e.g., to assist with scheduling appropriate follow-up visits or medication reconciliations post-discharge). • May be required to change work schedule to assist in covering for periodic “late clinics.” • 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 throughout their time enrolled in the CFSP. • Directs the extender’s care management functions and ensure that the extender supports allowable activities (e.g., coordinating services/appointments by arranging transportation, etc.). • Conducts a care management comprehensive assessment for each member • Develops a care plan (for members without I/DD and TBI needs) or an individual support plan (ISP) (for members with I/DD and TBI needs). o The care plan/ISP will provide a blueprint for ongoing care management and include the member’s health, social, emotional, educational and other service needs and relevant permanency planning information from the member’s assigned County Child Welfare worker or EBCI Family Safety Program staff as applicable, among other elements. o For members receiving treatment in a congregate setting (e.g., group home or PRTF), the member’s care plan/ISP will also identify the needed 4 services, supports, and timeline to facilitate the member’s transition to a family-based placement, as clinically appropriate. o Include standard timelines that care managers must meet for administering care management comprehensive assessments and developing each member’s care plan/ISP; the required timelines will differ for members identified as high-risk compared to members not identified as high-risk. o Delivery of the care management comprehensive assessment and development of the care plan/ISP must be accelerated, as needed, to manage members’ urgent needs/crises. • 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 establishing a multidisciplinary care team for each member. o For children, this multidisciplinary care team might include but is not limited to the member, the member’s assigned care manager, parent(s), guardian(s), or custodian(s) (as appropriate), the County Child Welfare worker, care manager extenders, and the member’s PCP. o For adults, the multidisciplinary team might include but is not limited to the member’s assigned care manager, the County Child Welfare worker, care manager extenders, and the member’s PCP. • Responsible for convening the care team on a regular basis (no less than twice per year, and more often, as appropriate) and will share 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 o For CFSP members who are served by the EBCI Family Safety Program instead of NCDSS or county DSS agencies, the CFSP will be required to coordinate with EBCI Family Safety Program staff in place of County Child Welfare workers. • Meet and coordinate with County Child Welfare workers (or EBCI Family Safety Program staff) to: o Share relevant health and health-related information, as permitted, and coordinate strategies to address members’ health and social needs to support and promote family preservation, permanency planning and reunification, as applicable o Assist with scheduling NCDSS-required health assessments, gathering medical records, and developing a crisis plan. Identify health and health related services that are necessary to support family preservation for families receiving CPS In-Home Services and reunification or other permanency planning efforts for children in foster care and their families o Obtain consent for treatment of certain health care conditions from a member’s parent(s), guardian(s), or custodian(s), unless there are 5 restrictions regarding such communication (e.g., termination of parental rights or court order restricting communication) in accordance with applicable North Carolina state law. • 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). o notify the County Child Welfare worker or EBCI Family Support Safety Program staff, as appropriate, and parents(s), guardians(s) and custodian(s), as appropriate, of a change in health plan and assist in selecting a new PCP, if necessary. o required to connect with the member before and after discharge, conduct discharge planning, facilitate clinical handoffs and arrange for medication reconciliation and management following discharge from a hospital or institutional setting or following an emergency department visit. • Collaborate with County Child Welfare workers as needed in the development of the NCDSS-required transitional living plan and 90-day transition plan. o identify key health-related resources and supports necessary to achieving the member’s health care goals o developing a Health Passport for each member as a supplement to the 90day transition plan. ▪ The Health Passport is a document, available electronically and in paper formats, which will contain critical health care-related information, such as upcoming scheduled visits, prescribed medications and the member’s medical records. • educate members about potential Medicaid and alternative insurance options available to them (e.g., Marketplace/Qualified Health Plan (QHP) coverage, applicable EBCI tribal programs/funding options, etc.) and assist them in signing up if desired, for former foster youth aging out of the Medicaid for Former Foster Care categorical Medicaid eligibility group • transitioning all ongoing health care services and medications. The Health Passport for these members must also include a list of health care resources available to members regardless of insurance status. • Responsible for ensuring members receive robust medication reconciliation and management. This will include, at minimum, medication reconciliation and management following health care and other life transitions (including placement changes), assistance with refilling medications, and leveraging CFSP clinical staff (e.g., psychiatrist) to assess the clinical appropriateness of members’ medication regimens. • Responsible for implementing the Healthy Opportunities Pilot (HOP) program for its HOP-eligible members, 6 • May be subject to on-call and callback. • Evaluates patient care provided. - Directly observes and evaluates patient care. - Revises nursing care and care plans to reflect changes in patient needs. - Documents nursing care and patient progress according to hospital policy. - Participates in ongoing nursing quality assurance program. • May be necessary to work when Administrative leave is granted if patient care would be compromised. Education, Licensure, Certification, and Experience • A bachelor’s degree and Five years of experience providing care management, case management, or care coordination to complex individuals with CSFP or foster care; or • A master’s degree in a human services field and Three years of experience providing care management, case management, or care coordination to complex individuals with CSFP or foster care. • If a RN, applicant must have an unrestricted valid Registered Nurse license within the state of North Carolina or a state that is accepted as reciprocity. • Current Basic Life Support (BLS) minimally required. Can be acquired through the facility within 6 months following appointment to position. • Specific experience working with Native Americans preferred. • Applicant must have a valid North Carolina driver’s license. Job Knowledge • 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 patient population. • Knowledge and ability to teach and counsel patient/family on health maintenance and disease prevention. • Knowledge of available health care programs and community resources. • Knowledge of problem oriented medical record methods. • 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. o In addition, have a working knowledge of the special needs of members who fall into the category of bei