Cherokee Indian Hospital Authority
Location: Cherokee,NC, USA
Date: 2025-01-03T08:21:36Z
Job Description:
Job Title: CSFP Care ManagerJob Code: CSFP CMDepartment: Tribal Option/ Primary CareDivision: Nursing/Tribal OptionSalary Level: Non-Exempt 12Reports to: CSFP Care Management SupervisorLast Revised: August 2024Primary FunctionThe 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.2Job 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 4services, 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 workero 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 5restrictions 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 goalso 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 orderto 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 being eligible for Tailored Care which includes those members with care needs related to a behavioral health condition (including both mental health and substance use disorders), intellectual/developmental disability (I/DD), or traumatic brain injury (TBI). Knowledge is required of and to have expertise in the systems and tools that are fundamental to the transition to adulthood, including independent living skills 7(e.g., accessing food and transportation), post-high school education, housing and employment options, self-advocacy, health insurance coverage options after Medicaid eligibility ends and building natural supports. Knowledge of ISP/Care Plan development and implementation for members of EBCI Tribal Option (TO) that are tailored plan eligible including the following:o Responsibility of the six core Health Home Services for the tailored plan Comprehensive care management Completion of care management comprehensive assessments and care plan/ISP Phone call or in-person meeting focused on chronic care management (e.g., management of multiple chronic conditions) Care coordination, including Working with the member on coordination across settings of care and services (e.g., appointment/wellness reminders and social services coordination/referrals) Assistance in scheduling and preparing members for appointments (e.g., phone call to provide a reminder and help arrange transportation) Health promotion, including Providing education on members' chronic conditions Teaching self-management skills and sharing self-help recovery resources Providing education on common environmental risk factors including but not limited to the health effects of exposure to second- and third-hand tobacco smoke and e-cigarette aerosols and liquids and their effects on family and children Comprehensive transitional care/follow-up, including Visiting the member during the member's stay in the institution and be present on the day of discharge Reviewing the discharge plan with the member and facility staff Referring and assisting members in accessing needed social services and supports identified as part of the transitional care management process, including access to housing Developing a 90-day post-discharge transition plan prior to discharge from residential or inpatient settings, in consultation with the member, facility staff, and the member's care team Individual & family support, including Providing education and guidance on self-advocacy to the member, family members, and support members 8 Connecting the member and parents/other family members/caregivers to education and training to help the member improve function, develop socialization and adaptive skills, and navigate the service system Providing 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 Referral to community & social support services, including Providing referral, information, and assistance and follow up in obtaining and maintaining community-based resources and social support services Providing comprehensive assistance securing key health related services (e.g., filling out and submitting applications) Person Centered Thinking/planning Knowledge of using assessments to develop plans of care Knowledge of LOC process, SIS for IDD and FASN assessment for TBI Knowledge of Medicaid basic, enhanced MH/SUD, and waiver benefits plans Knowledge of and skilled in the use of Motivational Interviewing and techniques Strong interpersonal and written/verbal communication skills Conflict management and resolution skills Proficient in Microsoft Office products (such as Word, Excel, Outlook, etc.) Ability to master care management platforms and review data for decision making and person-centered planning High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance. Ability to make prompt, independent decisions based upon relevant facts Good organizational skills to prioritize duties and work with minimal levels of onsite supervision to consistently meet deadlinesComplexity of DutiesComplies also with federal, state, accrediting and local regulations. These guidelines are not always specifically applicable to the individual patient or situation and independent 9judgment is required in selecting the most appropriate guideline, and applying the intent of the guideline to the specific situation at hand.Supervision ReceivedThe nurse independently plans, schedules, and provides nursing care in coordination with the medical care plan and attempts to solve problems only within established procedures. This is done under the supervision of the CSFP Care Management Supervisor and Assistant Director of Care Management. The work is evaluated for technical soundness and adherence to professional standards.Responsibility for AccuracyThe incumbent has a positive effect upon the recovery of the patient and is responsible for following policies and procedures, which serve as hospital guidelines and preventserrors from occurring. Errors can have a negative patient outcome since the incumbent's performance affects the health, recovery, and rehabilitation of patients, and the quality of care provided. Evaluations and observations are used to modify and develop clinically appropriate treatment plans. Work can be verified or checked by the immediate supervisor, other health care providers or systems checks, but usually the responsibility for accuracy relies solely on the incumbent.Contacts with OthersContacts are with patients, families, hospital personnel, and community agencies. Contacts with patients, families, and hospital personnel are to exchange, provide, and obtain information concerning the patient's physical and psychosocial health care problems, and needs. The nurse uses teaching and counseling methods to influence and motivate patient and family behavior. Contacts with other health care or related disciplines within the hospital are for the purpose of collaboration and consultation. Tact, courtesy, and professional conduct are required to maintain positive working relationships. Utmost sensitivity and confidentiality is required when dealing with patients and families.Confidential DataThe incumbent has access to highly confidential patient medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and all other pertinent information that comes to his/her attention or knowledge. The Act carries both civil and criminal penalties for unlawful disclosure of records. Violations of such confidentiality shall be cause for adverse action.Mental/ Visual/ PhysicalWork in the various services within the nursing department is mostly sedentary, yet requires walking, standing, bending, pushing, and lifting in helping patients to and from beds, wheelchairs, and stretchers. These same activities are required in moving equipment and medical supplies. Will be subject to frequent interruptions requiring varied responses, which can cause distractions therefore, the incumbent must possess the ability to differentiate and prioritize many tasks at once.10Work EnvironmentMust be flexible in working hours. Work is performed in the clinic setting, which is responsible for treating patients with a wide variety of medical problems. Incumbent may be exposed to communicable diseases. Incumbent is required to comply with Employee Health Program guidelines including current immunization status of identified communicable diseases and safety precautions are sometimes necessary, such as use of personal protective equipment as required by hospital policy. The work environment involves moderate risks of exposure to infectious disease, radiation, electrical hazards, irritant chemicals and explosive gases.Customer ServiceConsistently demonstrates superior customer service skills to patients/customers bydemonstrating characteristics that align with CIHA's guiding principles and core values. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.
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