Tailored Care Management- Extender

POSITION PURPOSE

The Care Manager Extender supports Tailored Care Management by assisting Care Managers in delivering integrated, whole-person care management to Tailored Plan members. The Care Manager Extender works as part of the care team to support members with behavioral health, physical health, intellectual/developmental disability (I/DD), traumatic brain injury (TBI), long-term services and supports (LTSS), pharmacy needs, and/or unmet health-related resource needs, as applicable to the member. The Care Manager Extender performs assigned functions under the direct supervision of a Care Manager and only within the extender's training, scope, and abilities. The Care Manager remains responsible for care management activities that must be performed solely by the Care Manager.

Care Manager-Only Activities

The Care Manager Extender does not independently perform the following Care Manager-only activities:

• Completing the care management comprehensive assessment.

• Developing the care plan for members with behavioral health needs or the individual support plan

(ISP) for members with I/DD and TBI needs.

• Facilitating case conferences.

• Ensuring medication monitoring and reconciliation occur.

• Continuously monitoring progress toward goals identified in the care plan or ISP.

• Managing care transitions, including creating 90-day transition plans.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

Under the direct supervision of the Care Manager, the Care Manager Extender may provide or support

the following:

• Performing general outreach, engagement, and follow-up with members.

• Coordinating services and appointments, including appointment and wellness reminders and

arranging transportation.

• Engaging members in health promotion activities and knowledge sharing.

• Sharing information with the Care Manager and other members of the care team regarding the

member's circumstances.

• Providing and tracking referrals and providing information and assistance in obtaining and

maintaining community-based resources and social support services.

• Participating in case conferences as directed by the Care Manager.

• Supporting the Care Manager in assessing and addressing unmet health-related resource needs.

• Providing information and assistance that supports members and caregivers in accessing appropriate

services, supports, and community resources.

• Promoting member engagement, community integration, wellness, and self-sufficiency within the

scope of the position.

• Maintaining regular communication with the assigned Care Manager and coordinating outreach

efforts to reduce duplicative or inappropriate member contacts.

• Documenting outreach, contacts, referrals, coordination activities, and other assigned functions in

accordance with DSIS policies, procedures, and applicable Tailored Care Management requirements.

• Performing other duties and responsibilities as assigned by the Care Manager or supervisor,

consistent with the employee's training, scope, and abilities.

Scope of Services

Care Manager Extenders will use best efforts to ensure that assigned services and support activities are

performed promptly, timely, responsibly, and in accordance with DSIS policies and procedures, North

Carolina Department of Health and Human Services requirements, and the Care Manager's direction.

TRAINING REQUIREMENTS

Staff must maintain all trainings as required by State and Federal law and regulations and must complete

the full Tailored Care Management training curriculum required for Care Manager Extenders, including

applicable practical or hands-on training and evaluation.

Training topics include, as applicable:

• Tailored Plan eligibility and services.

• Whole-person health and unmet health-related resource needs.

• Components of Health Home/Tailored Care Management.

• Ethics, boundaries, and personal safety.

• Building a trusting relationship.

• Community integration.

• Health promotion.

• I/DD- and TBI-specific training, when serving members from these populations.

• Transitional care management.

• Skills to support health behavior change, including motivational interviewing.

• Person-centered needs assessment and care planning, including LTSS and other needs.

• Preparing members for and assisting them during emergencies and natural disasters.

• Infection control and prevention practices.

• Understanding virtual/telehealth applications.

• Needs of justice-involved individuals.

• Additional training applicable to children, children with complex needs, pregnant and postpartum

persons with substance use disorder or a history of substance use disorder, and members with LTSS

needs.

Qualifications

Employees must possess the education, training and experience to work with the population served in the

capacity and at the level of intervention for which hired.

Care Manager Extenders serving Tailored Plan members must meet the following minimum requirements:

• Be at least 18 years of age.

• Have a high school diploma or equivalent.

• Complete required Tailored Care Management training.

• Be supervised by a Care Manager and meet at least one of the following experience/qualification

pathways:

• Be a person with lived experience with an I/DD or TBI with demonstrated knowledge of and direct

personal experience navigating the North Carolina Medicaid delivery system.

• Be a person with lived experience with a behavioral health condition who is a Certified Peer

Support Specialist.

• Be a parent or guardian of an individual with an I/DD, TBI, or behavioral health condition and have

at least two years of direct experience providing care for and navigating the Medicaid delivery

system on behalf of that individual. A parent or guardian may not serve as an extender for their

own family member.

• Have two years of paid experience performing the types of extender functions described in the

Tailored Care Management guidance, with at least one year of paid experience working directly

with the Tailored Care Management eligible population.

Examples of individuals who may meet the extender qualifications include Certified Peer Support

Specialists, Community Health Workers who have completed the NC Community Health Worker

Standardized Core Competency Training, Community Navigators, Family Navigators as defined by an

approved LME/MCO in lieu of service description, parents or guardians meeting the applicable

requirements, and persons with lived experience with an I/DD, TBI, or behavioral health condition.

Certificates, Licenses, Registrations

Must maintain any certifications, registrations, and other credentials required by DSIS, the North Carolina

Department of Health and Human Services, the applicable Tailored Plan, and/or State and Federal law

and regulations for the position and assigned population.