Complex Care Consultant (RN) (Full time Hybrid Morrisville, North Carolina based)

Complex Care Consultants RN address the co-occurring complex medical and functional needs for members transitioning out of Adult Care Homes (ACH) and into the community and facilitate the provision of essential services needed to allow Transition to Community Living (TCL) individuals to make and sustain an effective transition from ACHs to community-based supported housing. 

This position will require regular visits with members in Adult Care Homes and with members living in the community, resulting in significant travel.

This position will allow the successful candidate the ability to work hybrid schedule with one day a week onsite and requires face-to-face visits when needed. This position will require regular visits with members in Adult Care Homes and with members living in the community, resulting in significant travel.  The hire may be asked to complete reviews for all catchment areas including Cumberland, Wake, Orange, Durham, Harnett and Johnston county. If member facing visits occur during the week, office days are not required; otherwise, 1 office day/week is required.

Responsibilities & Duties

Provide Care Team Support

• Support members transitioning from institutional care settings to community-based care.
• Provide subject matter expertise, within scope of license, regarding member’s physical 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

Complete Assessments and Planning

• Utilize person-centered planning, motivational interviewing, and assessments to gather information
• Perform individual assessments/screenings for members that are medically fragile or have significant health conditions, have a mental health condition, substance use condition, or co-occurring intellectual or developmental disability.
• In the Transition and Housing setting, staff will also assess and record member’s activities and progress.
• Provide education and supports to members and/or legal guardians regarding self-care strategies, their rights and responsibilities, available treatment options, provider network availability and payor requirements that may impact service access or maintenance
• Educate team members about impact of member’s health conditions on service engagement, clinical outcomes, and prognosis for change
• Actively collaborate with member and care team members to ensure care plan accurately reflects the individual’s clinical needs and desired life goals
• Update Assessments and plans of care as needed
• Provide education about advanced directives, preferred natural support and physical health contacts whom the member identifies, and preferred crisis facilities
• Provide medication reconciliation and education
• Develop and update plans of care based off the needs identified in the assessments and complete the interventions identified as needed
• Review member’s medical history and identify specific goals and types of activities that will be used to help member work to help work towards those specific goals
• Proactively works with the member’s multidisciplinary care team to identify gaps in services and intervenes to ensure that the member is receiving the appropriate level of care
• Complex Care Management OT staff may evaluate a member’s home and based on member’s needs, may identify needed improvements and/or special durable medical equipment and instruct member’s on how to use this equipment

Monitoring/Coordination

• The CCM team will continue to be involved with the member for 90 days after the move to provide additional support and recommendations that may be needed to reduce crisis service/inpatient utilization and retain housing
• Appropriately escalate high risk/high visibility and/or complex barriers/needs members who may have difficulty transitioning out of the facility in a timely manner to supervisors. High risk can involve Health and Safety of a member, staff, or organizational risk
• Review cases with clinical complexity with direct supervisor, peer clinical review cohort, and utilization management care managers and medical management leadership as needed
• Obtain information releases that will improve care management activities on behalf of the member
• Reports care quality concerns to Quality Management as needed

Documentation

• Ensure all clinical documentation (e.g. goals, plans, progress notes, etc.) meet state, agency, and Medicaid requirements
• Follow administrative procedures and effectively manages caseload

Data