Tribal Option Care Management Extender - IDD

Primary Function

Care management extenders serve individuals who are eligible for Tailored Care Management, Intellectual Developmental Delays/Traumatic Brain Injury (I/DD/TBI), Long Term Service or Supports (LTSS) or those who are in the Children and Families Specialty Program (CSFP). Members require assistance to help them gain access to necessary care: medical, behavioral, social, community and other services appropriate to their needs. Services include person centered planning, referral and linkage, monitoring and follow-up. The duties of this position would include, but not limited to, representing care management when working with members, families, caregivers, as well as, other entities where a member may be seeking care, reside or receive services from.

Job Description

• Provide the following care management functions according to CIHA policy: assist with person centered planning; referral and linkage; and monitoring and follow-up.
• Ensuring that the care plan activities are carried out under the direction and/or delegation of the care manager or care manager supervisor.
• When assigned to provide services for adults, or for children and families, the employee will fulfill duties as outlined in EBCI TO policy and procedure for care management related to the specific population served.
• Gather and document necessary information in the EHR and/or the care management platform including medical, physical and functional, psychosocial, behavioral, financial, social, cultural, environmental, legal, and vocational or educational areas.
• Provides documentation of all significant events in Electronic Health Record and/or the care management platform, as prescribed by EBCI TO policies and procedures and quality assurance standards.
• Engage members in the person centered planning process, that is determined by the member’s care plan, to assist them in obtaining the outcomes, skills, and symptom reduction they desire.
• Link clients to needed services and supports.
• Provide timely information to care team members regarding member status, progress and safety.
• Collaborate with the medical staff and other health professional/agencies to facilitate patient care, discharge and follow-up.
• Assist the care team in providing consultation to patient and family in matters directly related to patients' limitations, finances, adjustments to medical condition and ongoing treatment.
• Work with internal and external providers, and the member’s care team, to coordinate discharge planning, follow-up care, and transfers to other health facilities as appropriate.
• Responsible for attending staffing huddles, as an integral component of a care team, participating in the discussion of client data, and the formulation changes to the care plan/ISP.
• Participate in meetings to review and identify opportunities to improve care provided, and support the team in problem solving when concerns are identified.
• Participate in and assist with facilitating written, telephonic and face-to-face consultation services to various persons and organizations which affect the member. These include schools, courts, probation officers, physicians, hospitals, medical care providers, law enforcement officers, social services, community agencies, etc.
• Provide support to members in the office setting, as well as, the community setting by participating in the conducting of home visits with patients and staff, as needed.
• Collect and report on data necessary for member care according to procedure and as directed by supervisor.
• Arrange to visit the member in the new care setting after discharge/transition.
• Performs general outreach, engagement, and follow-up with members;
• Provide coordination of services/appointments (e.g., appointment/wellness reminders, arranging transportation).
• Participate in health promotion activities (as defined in the Tailored Care Management Provider Manual) and knowledge sharing.
• Shares information with the care manager and other members of the care team on the member’s circumstances, including gathering information about the member’s progress toward their goals.
• Provides and tracks referrals and provides information and assistance in obtaining and maintaining community-based resources and social support services.
• Participates in case conferences/Huddles.
• Support the care manager in assessing and addressing unmet health-related resource needs.
• Facilitate arrangements for and scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven calendar days, unless required within a shorter time frame.
• Other duties as assigned.
• Support the TO Care Managers as needed.
• May be necessary to work when Administrative Leave is granted if patient care would be compromised.

Education/Experience/Minimum Qualifications

Care manager extenders must have the following qualifications:

• At least 18 years of age; and
• A high school diploma or equivalent (e.g., GED, certificate of completion); and
• Employees who work with individuals who are Tailored Care Management eligible and/or IDD/TBI, must meet one of the following requirements:
• Be a person with lived experience with an I/DD or a TBI with demonstrated knowledge of and direct personal experience navigating the North Carolina Medicaid delivery system; or
• Be a person with lived experience with a behavioral health condition who is a Certified Peer Support Specialist; or
• A parent or guardian of an individual with an I/DD or a TBI or a behavioral health condition and has at least two years of direct experience providing care for and navigating the Medicaid delivery system on behalf of that individual (note that a parent/guardian cannot serve as an extender for their family member); or
• Has two years of paid experience performing the types of functions described in the essential duties and responsibilities section above, with at least one year of paid experience working directly with the Tailored Care Management eligible population.
• Employees who work with individuals who are enrolled in CFSP, must meet one of the TCM and IDD/TBI requirements above or meet one of the following requirements:
• Certified Family Peer Specialist (Family Partners)
• Certified Peer Support Specialist
• Community health worker
• Must possess valid drivers' license.
• Specific experience working with Native Americans preferred.
• Current Basic Life Support (BLS) minimally required. Can be acquired through the facility within 6 months following appointment to position.

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