I/DD Community Integration Care Manager (Hybrid- NC based role)

The IDD Community Integration CM position provides a critical support to Alliance members with I/DD to successfully integrated from an institutional setting into independent community living settings of their choice. Responsibilities include building relationships and rapport with members and providers through in reach activities, with ongoing support transitioning into the community, and care management once in the community. Additional diversion planning and coordination is provided to members for their success in remaining in a community setting. This role is hybrid, requiring facility visits and home visits to meet member needs.

This position is primarily a remote role however there will be times where you will have to go into the field to do on site client visits or attend scheduled Alliance meetings. 

Responsibilities & Duties-

Assessment & Monitoring

• Document member and/or legally responsible person (LRP) consent to participate in the transition process and care management efforts 
• Within defined timelines, complete assessment of the member preferences and needs related to integrated community living through active listening, meaningful conversation, motivational interviewing, and the use of open-ended questions
• Assess the whole person including physical, psychological, social, environmental, and spiritual needs
• With appropriate consent, as applicable, collaborate with formal and informal caregivers or support network, providers, and others in the member’s interdisciplinary healthcare team to inform the assessment
• Document the assessment findings, including not limited to, the member’s support systems (professional and informal), primary concerns, strengths, priorities, care need gaps, social needs, goals, etc.
• Document member and/or LRP agreement regarding the identified care needs, opportunities, and goals for intervention identified through the assessment process
• During member engagements and through available data related to resource utilization and quality metrics, monitor the member’s condition and response to the care plan and interventions
• Document ongoing collaboration and engagement with the member, LRP, and others involved in the member’s care and support to reflect the member’s response to interventions and the care plan
• Document new findings, barriers to care and services, and/or continued effectiveness of the current care plan, with notation of member’s understanding of and agreement with the assessment
• Through ongoing, routine and ad hoc follow-up with the member and/or their support network, monitor progress towards goals and/or revise goals appropriately to be relevant and realistic with member input and agreement
• Collaborate with member/LRP on progress towards goals met to determine appropriate time to end current episode of care management once transitioned into a community living setting of their choice

 Care Planning

• Based on assessment and member identified priorities, develop a member centric and agreed upon care plan in collaboration with appropriate and applicable formal and informal caregivers or support network, providers, and others in the member’s interdisciplinary healthcare team
• Use of a member-centric, collaborative partnership approach that is responsive to the individual member’s culture, preferences, needs, and values
• Develop care plan with a comprehensive, holistic, and compassionate approach to care delivery that integrates a member’s medical, behavioral, social, psychological, functional, and other needs
• Consideration for the member’s care needs, barriers, and opportunities in development of the care plan
• In collaboration with the member and their support network (formal and informal) include prioritized goals and outcomes to be achieved with associated interventions or actions needed to reach the goals
• Include appropriate, relevant, and realistic goals to align with member needs and priorities
• With reassessment, new findings, or member request, make any revisions or modifications needed to the care plan goals or interventions to influence positive member outcomes. Review with member for understanding of and agreement with revisions or updates to the care plan

In Reach, Transition, Care Coordination & Collaboration

• Facilitating awareness of and connections with community supports and resources to support successful integration into and sustained success with community living
• 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 while providing comprehensive assistance securing key health-related services (e.g., filling out and