Ensure the provision of Person-Centered Planning for all service delivery.
Conducts outreach and engagement activities to engage members in care management.
Conducts comprehensive assessment and reassessments within the required timeframes for acuity level of member.
Facilitates the completion of the care plan, as well as ISP for Innovation Waiver services for members receiving waiver services, inclusive of crisis and safety plan.
Makes referrals to community resources for primary and specialty medical care, physical well-being, mental health.
Monitor notification of admissions and discharges of ER and hospitalizations.
Coordinate members’ medication reviews and reconciliation.
Facilitate proactive planning for transitional care support (pre-discharge).

A bachelor’s degree from an accredited college or university in a field related to health, psychology, sociology, social work, nursing or another relevant human services area, or licensure as a registered nurse (RN).
Two (2) years of experience working directly with individuals with an I/DD.
Two (2) years of prior LTSS and/or HCBS coordination, care delivery monitoring, and care management experience.
Must have a valid North Carolina driver’s license and be insurable by the agency’s insurance carrier.
Knowledge and experience with NC Medicaid and Innovation Waiver.
Excellent skills and proficiency in Microsoft Word, Google Suite, Excel, and navigating internet.
Demonstrated skill with using Electronic Health Record and care management platforms.
Ability to prepare clear, accurate and effective reports and other written materials.
Ability to establish and maintain effective, collaborative relationships with internal staff, external stakeholders, and members.

TLC

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