Complex Care Consultant (RN) (Full time Hybrid, Charlotte, North Carolina b

at  Alliance Health

Complex Care Consultants 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.

EDUCATION & EXPERIENCE

Graduation from a school of nursing and two years of full-time experience with the population served and active NC or Compact Registered Nurse License

PREFERRED EXPERIENCE

Home & Community based service

KNOWLEDGE, SKILLS, & ABILITIES

• Demonstrated knowledge of the assessment and treatment of mental health, substance abuse, intellectual and developmental disabilities,
• Knowledge of legal, waiver, accreditation standards and program practices/requirements.
• Knowledge of the Alliance Health service benefit plans and network providers.
• Person Centered Thinking/planning
• The employee must be detail oriented,
• Ability to independently organize multiple tasks, priorities, and to effectively manage an assigned caseload under pressure of deadlines.
• Exceptional interpersonal skills, highly effective communication ability,
• Ability to make prompt independent decisions based upon relevant facts and established processes.
• Problem solving, negotiation and conflict resolution skills
• Proficiency in Microsoft Office products (such as Word, Excel, Outlook, etc.) is required.

EXACT COMPENSATION WILL BE DETERMINED BASED ON THE CANDIDATE’S EDUCATION, EXPERIENCE, EXTERNAL MARKET DATA AND CONSIDERATION OF INTERNAL EQUITY.

An excellent fringe benefit package accompanies the salary, which includes:

• Medical, Dental, Vision, Life, Long Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility

EDUCATION

Preferred

• Associates or better in Nursing
• Masters or better in Occupational Therapy

SKILLS

Required

• Person Centered Thinking/Planning
• Communication
• Interpersonal Skills
• Microsoft Office
• Multitasking

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

• Review, validate and interpret risk stratification data and population health groups and recommend changes or adjustments to care management approach as needed
• Utilize data to analyze needs of the members we serve, guide staff training development, identify resource needs and consistency of workflow implementation across disciplines

Travel

• Travel to meet with members, providers, stakeholders, attend court hearings etc. is required