Care Manager II-Facility Based (Full-time Remote, North Carolina Based)

Responsibilities & Duties-

• Provide Care Team Support
• Support members transitioning from inpatient settings to the appropriate and least restrictive lower or lateral level of care
• Provide subject matter expertise, within scope, regarding member’s physical and/or behavioral health to support the development and delivery of a whole person approach to Care Management
• Work collaboratively with other Alliance staff, behavioral health providers, primary care physicians, specialty care providers and other community partners and stakeholders to support members in their home communities and address barriers
• Core Transitional Care Management Functions
• Conducts on site visit the member during their stay in an institution (e.g., acute, subacute and long–term stay facilities)
• Conduct outreach to the member’s providers
• Obtain a copy of the discharge plan ensure discharge plan is made available to authorized community providers who will be serving the member post discharge
• Facilitate clinical handoffs to other Health Plans and Providers as applicable
• Refer and assist members in accessing needed social services and supports identified as part of the transitional care management process, including access to housing, behavioral health services, residential services and supports, medical and wellness services
• Assist the member in obtaining needed medications prior to discharge, ensure an appropriate care team member conducts medication reconciliation/management and support medication adherence
• Develop a ninety (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, that outlines how the member will maintain or access needed services and supports, transition to the new care setting, and integrate into their community
• Communicate and provide education to the member and the member’s caregivers and providers to promote understanding of the ninety (90) day post-discharge transition plan
• Assist with scheduling of transportation, in-home services, and follow-up outpatient visits with appropriate providers within a maximum of seven (7) Calendar Days post-discharge, unless required within a shorter timeframe
• Conduct In reach and transitions for Special Populations receiving care in Inpatient settings (PRTF, SNF’s)