Remote Claims Processing Jobs in Raleigh, NC (NOW HIRING)

The Care Manager l - Waiver assures that individuals and families with special health care needs receive integrated whole-person-person centered care management, including coordinating across physical health, behavioral health, pharmacy and unmet health-related resource needs to ensure they are linked to services and supports in an effort to maximize potential outcomes and decrease the unnecessary use of hospitals and emergency services by assuring that appropriate quality care is in place.

The Care Manager I focus on a specified population of members utilizing health care services while ensuring all member health needs and referrals are addressed. The Care Manager l will collaborate with other community systems to work in partnership to support the identified population. 

This position is full time remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the home office and within the Wake, Johnston, Durham counties member visits may be required. 

Responsibilities & Duties

 Complete Assessment/Planning

• Complete comprehensive assessments or Care Needs Screening at enrollment, yearly or at changes in condition
  
• Develop Plans of Care derived from the completed assessments
  
• Demonstrate commitment to whole person/integrated care
  
• Assign interventions/plans of care to applicable Alliance Care Management team member to meet identified member needs, for monitoring, and/or service engagement activities 
  
• Complete required Screening Tools
  
• Retrieve and review historical data to better-understand member’s treatment history
• Submit referrals to the Transition Coordinator when a physical health or behavioral health need indicates medical and/or pharmaceutical complexity 
  
• Assign Plan of Care activities to Community Health Worker if member has identified Social Determinants of Health (SDOH), disparities and/or complex payer issues
  
• Assist individuals/legally responsible persons (LRP) in choosing service providers, ensuring objectivity in the process
  
• Consistently evaluate appropriateness of services and ensure implementation of plan of care through information gathering and assessment at defined frequency of contact based on risk stratification 
  
• Utilize person centered planning, motivational interviewing and historical review of assessments in JIVA to gather information and to identify supports needed for the individual
  
• Assist in collecting data to be used to identify and address barriers as well as determine the effectiveness of care management/care coordination in reducing lengths of stay and use of emergency services
  
• Actively collaborates with members/legally responsible person, care team, service providers, and identified supports to ensure development of a plan that accurately reflects the individual’s needs and desired life goals including collaborating with residential placement search in conjunction with internal team members or external stakeholders as needed
  
• Submits required documentation to UM to ensure timely delivery of services - and trouble shoot until authorization is obtained.  Notify a member’s care team and providers of successful authorization (for residential or waiver related services)
  
• For Medicaid C, enlist administrative support to send Level of Care (LOC) and initial Individual Service Plan (ISP) to Department of Social Services (DSS) to turn on special waiver program indicator.  Verify that necessary Client, Employer, Group (CEG) enrollments are correct in JIVA, and that Medicaid eligibility is updated in Alliance Claims System

Provide Support and Monitoring to Members

• Schedule initial contact with member for purpose of assessment and engagement 
  
• Verify accuracy of demographic information with member.  Update inaccurate information from the Global Eligibility File following documented protocols
  
• Schedule face to face, virtual, and telephonic meeting with member/guardian to provide education about Alliance Health Plan, care teams, resources, and services 
  
• Provide education and support, to individuals and LRP, in learning about and exercising rights, explanation of the grievance and appeals process, available service options, providers available to meet their needs, and payer requirements that may impact service connection and maintenance
  
• Refer members who are in crisis/institutional setting and require assistance with returning to community based services to the Integrated Health Consultant or applicable care team member
  
• Recognize and report critical incidents and provider quality concerns to supervisors and Quality Management Department
  
• Complete activities in JIVA related to Plans of Care developed from the Care Management Comprehensive Assessment or other assessments as deemed necessary
  
• Coordinate with other team members to ensure smooth transition to appropriate level of care when needed
  
• Communicate with member to check on status, verify care needs are met and that no new clinical needs warrant a change in condition assessment
  
• Provide follow up coordination with key stakeholders to promote engagement 
  
• Promote customer satisfaction through ongoing communication and timely follow-up on any concerns/issues 
  
• Verify that ongoing service adherence is maintained through monitoring meetings with member and/or guardian or provider 
  
• Identify barriers to treatment and assist individuals with arranging appointments or linking to treatment providers
  
• Maintain required contacts with member/legally responsible person per state contractual requirements meeting minimum expectations
  
• Attend community, provider, stakeholder meetings as needed for member and/or as directed to support the needs of the health plan
  
• Coordinate and participate with SIS Team to ensure successful completion of SIS assessment within time frames allotted  
  
• For facility (ICF, Hospital, PRTF or SDC) discharges, inform SIS Supervisor that an assessment needs to be scheduled
• Schedule and facilitate the ISP meeting, develop and update ISP
  
• Submit requests for services and purchase orders for products, supplies, and services covered under the Innovations waiver
  
• Complete check-in/contact with member and/or legally responsible person (LRP) via phone or email 
  
• Complete Home and Community Based Services (HCBS) Notice of Change Form when arranging new HCBS service placement (for Residential Supports, Day Supports, and Supported Employment) with a new provider and submit to Provider Network department to ensure successful transition to provider
  
• Review service utilization and documentation as required by the member’s program enrollment to monitor progress toward individualized goals and fulfillment of the intent of the service authorized
  
• Proactively respond to an individual’s planned movement outside the Alliance MCO geographic area to ensure a smooth transition without lapse in care

Engage with Providers

• Engage with Providers to identify barriers to service delivery at the member level and work toward individualized resolution with both the member and provider
  
• Ensure assessments, person-centered plans, discharge plans, and crisis plans are completed and shared with providers with whom the individuals are linked
  
• Report changes in member’s health status to authorized providers

Service Monitoring

• For Medicaid C services: conduct in-person, field-based observation of the member’s experience with service delivery per the frequency and requirements outlined in the Medicaid C waiver and Home and Community-based Services (HCBS) standards
  
• For Non-Medicaid C services: complete (a) Provider Engagement Tool to assess provider support needs (to engage member in services) and (b) interventions to resolve administrative barriers to care;
  
• Review service utilization and documentation as required by the member’s program enrollment to monitor progress toward individualized goals and fulfillment of the intent of the service authorized

Complete Documentation

• Obtain and upload all supporting documentation, Legally Responsible Person (LRP) verification, and release of information that will improve care management activity on behalf of the member
  
• Open new episodes in JIVA when needed and schedule initial contact with member to verify accuracy of demographic information and initiate the rapport building process
  
• Document all applicable member updates and activities per organizational procedure
  
• Escalate complex cases and cases of concern to immediate supervisor.
  
• Ensure that service orders/doctor’s orders are obtained, as applicable  
  
• Share appropriate documentation with all involved stakeholders as consent to release is granted 
  
• Obtain releases/documentation and provide to all stakeholders involved 
  
• Maintains medical record compliance/quality
  
• Proactively respond to an individual’s planned movement outside the Alliance geographic area, or other transition need, to ensure a smooth transition without lapse in care
  
• Distribute surveys to members in service
  
• Ensure clinical documentation (e.g. goals, plans, progress notes, etc.) meets state, agency documentation standards, and Medicaid requirements

Compliance with Alliance Policy and Procedure

• Adheres to all Alliance Organizational Policies and Procedures and Care Management  Desk Procedures

 Travel

• Travel between Alliance offices, attending meetings on behalf of Alliance, participating in Alliance sponsored events, etc. may be required
• Travel to meet with members, providers, stakeholders, attend court hearings etc. is required

Minimum Requirements

 Bachelor’s degree from an accredited college or university in Human Services field and two (2) years of post-bachelor’s degree mh/dd/sa experience with the population served. Experience must include two (2) years LTSS and/or HCBS coordination, care delivery monitoring, and care management experience. 

Or

Bachelor’s degree from an accredited college or university in Non-Human Services field and four (4) years of post-bachelor’s degree mh/dd/sa experience with the population served. Experience must include two (2) years LTSS and/or HCBS coordination, care delivery monitoring, and care management experience.

Or

Master’s Degree from an accredited college or university in Human Services field and one (1) year of post graduate degree mh/dd/sa experience with the population served. Experience must include two (2) years LTSS and/or HCBS coordination, care delivery monitoring, and care management experience.

Or 

Fully or Provisionally Licensed in the State of North Carolina as a LCSW, LCMHC, LPA, or LMFT and two (2) years LTSS and/or HCBS coordination, care delivery monitoring, and care management experience.

Or

Licensed Registered Nurse (RN) in the State of North Carolina with four (4) years of mh/dd/sa experience with the population served. Experience must include two (2) years LTSS and/or HCBS coordination, care delivery monitoring, and care management experience.

Preferred: NACCM, NADD-Specialist and/or CBIS Certification

Knowledge, Skills, & Abilities

•  Person Centered Thinking/planning
• Knowledge of using assessments to develop plans of care
• Knowledge of LOC process, SIS for IDD and FASN assessment for TBI
• Knowledge of Medicaid basic, enhanced MHSUD, and waiver benefits plans
• Knowledge of and skilled in the use of Motivational Interviewing techniques
• Strong interpersonal and written/verbal communication skills
• Conflict management and resolution skills
• Proficient in Microsoft Office products (such as Word, Excel, Outlook, etc.)
• High level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance.
• Ability to make prompt, independent decisions based upon relevant facts

Employment for this position is contingent upon a satisfactory background and MVR (Motor Vehicle Registration) check, which will be performed after acceptance of an offer of employment and prior to the employee's start date.

Salary Range

$28.96 - $37.65/hourly

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