Cherokee Indian Hospital
Tribal Option Specialty Team Care Manager (LTSS)
Cherokee Indian Hospital, Raleigh, North Carolina, United States
Tribal Option Specialty Team Care Manager
Join to apply for the Tribal Option Specialty Team Care Manager role at Cherokee Indian Hospital.
Primary Function The Tribal Option Specialty Team Care Manager is responsible for proactive intervention and care coordination for members eligible for Tribal Option, ensuring they receive appropriate assessment and services. The Care Manager will be assigned to one of the three Tribal Option Specialty Teams: I/DD/TBI/LTSS, Adults and Children with Special Health Care Needs, and Children and Families served by the child welfare system.
The Care Manager works with members and the care team to reduce inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, and coordination of services needed across mental health, substance use, intellectual/developmental disability, traumatic brain injury, child welfare, and unmet health‑related resource needs. The goal is to improve members’ near‑ and long‑term physical and behavioral health outcomes.
The Care Manager assists members in developing their care plan/ISP based on the member’s and legally responsible person’s needs and desires. Plans are person‑centered and reflect all areas of support needed, coordinating the member’s whole‑person care—physical, behavioral, pharmacy, behavioral health, long‑term services, IDD, TBI, and unmet social or health‑related resource needs such as vocational, education, social supports, personal safety, housing, and food insecurity.
The Care Manager coordinates care and facilitates transitions for members experiencing changes in treatment settings, child welfare placements, transitions to adulthood, and/or loss of Medicaid eligibility. This includes coordination with county DSS agencies, EBCI Family Safety program, and Community Collaboratives to ensure seamless transitions and appropriate after‑care services.
Guiding Principles
Broad access to care management—available to all eligible individuals continuously, with limited exceptions.
Dedicated care manager providing an integrated, whole‑person approach with expertise in behavioral health, I/DD, LTSS, TBI, and unmet health‑related resource needs.
Person and family‑centered planning—care plans are person‑centered and consider unique needs; parents, family members, and caregivers may be included with consent.
Job Description
Utilize best practice models to identify, incorporate, or develop panel‑management best practices.
Collaborate with other teams to share and establish best practices for health promotion and disease prevention strategies.
Manage assigned panel by addressing and resolving acute and chronic care needs through a team‑based approach.
Use electronic health records to track and monitor members’ follow‑up and health indicators.
Document care management functions—needs screening, comprehensive assessment, and care planning—in the care management platform.
Apply dashboards and population health tools for interventions and innovations to address care gaps.
Use NC Health Connects for information gathering and data collection.
Coordinate and follow up on referrals to outside specialty providers, recent ED visits, and ICC visits.
Coordinate and follow up on recent admissions and discharges.
Provide member education on health assessment, disease processes, medications, treatment plans, and community resources.
Assess member needs using established clinical guidelines, protocols, and pathways.
Collect data on biological, psychological, social, and cultural factors influencing health status and incorporate this data into member‑centered care plans.
Interpret data and recognize relationships between data and member’s health status to determine need for immediate interventions.
Initiate individualized care plans based on assessments, considering social determinants of health and human behavior while adhering to standards of care.
Develop individualized plans of care with input from the member, family, and others requested for high‑risk members.
Define expected member outcomes that are observable, time‑bound, and aligned with the member’s capabilities.
Assist in establishing a multidisciplinary care team for each member.
Coordinate closely with each member’s primary care provider, care manager extenders, county child welfare workers, EBCI Family Safety staff, CIHA Care Team, family members, and guardians.
Assume coordination responsibility for transition planning and provide best effort contact during inpatient psychiatric or hospital stays.
Provide transitional care management during care transitions, including from intensive treatment settings to foster care homes or community placements.
Obtain copies of discharge plans, review with member and facility staff, and facilitate clinical handoffs.
Ensure robust medication reconciliation and management; support medication adherence.
Direct extender care‑management functions and ensure allowable activities are performed.
Implement the Healthy Opportunities Pilot (HOP) program for HOP‑eligible members.
Facilitate additional requirements for members obtaining 1915(i) services.
Provide 24/7 support during emergencies or behavioral health crises when required.
Convene the care team at least twice per year and share the care plan/ISP with the team and other representatives.
Coordinate closely with county child welfare workers and EBCI Family Safety staff on transitional living plans.
Participate in required agency trainings, state trainings, and payor trainings within assigned timeframes.
Travel to community locations, agencies, and outreach destinations as necessary.
Maintain all certifications or licensure required for the position.
Demonstrate awareness and knowledge of agency policies, procedures, and regulatory requirements.
Meet minimum monthly contacts and effectively engage with members.
Participate in 24‑hour coverage for emergency medical conditions and behavioral health crises.
Be prepared for on‑call and callback duties and occasional work beyond standard hours.
Undergo annual evaluation of performance and problem‑solving skills.
Education, Licensure, Certification, and Experience
Meet North Carolina’s definition of a Qualified Health Professional per 10A-NCAC 27G.0104.
Qualified profesional within the mh/dd/sas system of care includes a registered nurse licensed in North Carolina with four years of full‑time experience in mh/dd/sa, or a graduate with a Master’s in a human service field and one year of full‑time supervised mh/dd/sa experience, or similar credentials for substance abuse professionals.
For LTSS needs: two years of prior LTSS/HCBS coordination experience in addition to above requirements.
Preferred experience working with Native Americans.
Current Basic Life Support (BLS) required; can be obtained within 6 months.
Valid North Carolina driver’s license.
Job Knowledge
Ability to plan, manage, and organize work to meet priorities within established time frames and under stressful conditions.
Understanding of multidisciplinary health care team functions.
Communication skills—strong interpersonal, written, and verbal.
Conflict management and resolution skills.
Proficiency in Microsoft Office (Word, Excel, Outlook).
Capability to master care‑management platforms and interpret data for decision making.
Diplomacy and discretion in negotiating and resolving issues independently.
Organizational skills to prioritize duties and meet deadlines with minimal supervision.
Working knowledge of special needs of members eligible for Tailored Care Management services.
Expertise in transition‑to‑adulthood systems and skills (accessing food, transportation, housing, employment, insurance options).
Utilization of motivational interviewing techniques and other engagement tools.
Additional Information Travel may be required. Some overnight travel may be necessary for meetings or training. The position supports a hybrid work model with flexibility for remote work.
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Primary Function The Tribal Option Specialty Team Care Manager is responsible for proactive intervention and care coordination for members eligible for Tribal Option, ensuring they receive appropriate assessment and services. The Care Manager will be assigned to one of the three Tribal Option Specialty Teams: I/DD/TBI/LTSS, Adults and Children with Special Health Care Needs, and Children and Families served by the child welfare system.
The Care Manager works with members and the care team to reduce inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, and coordination of services needed across mental health, substance use, intellectual/developmental disability, traumatic brain injury, child welfare, and unmet health‑related resource needs. The goal is to improve members’ near‑ and long‑term physical and behavioral health outcomes.
The Care Manager assists members in developing their care plan/ISP based on the member’s and legally responsible person’s needs and desires. Plans are person‑centered and reflect all areas of support needed, coordinating the member’s whole‑person care—physical, behavioral, pharmacy, behavioral health, long‑term services, IDD, TBI, and unmet social or health‑related resource needs such as vocational, education, social supports, personal safety, housing, and food insecurity.
The Care Manager coordinates care and facilitates transitions for members experiencing changes in treatment settings, child welfare placements, transitions to adulthood, and/or loss of Medicaid eligibility. This includes coordination with county DSS agencies, EBCI Family Safety program, and Community Collaboratives to ensure seamless transitions and appropriate after‑care services.
Guiding Principles
Broad access to care management—available to all eligible individuals continuously, with limited exceptions.
Dedicated care manager providing an integrated, whole‑person approach with expertise in behavioral health, I/DD, LTSS, TBI, and unmet health‑related resource needs.
Person and family‑centered planning—care plans are person‑centered and consider unique needs; parents, family members, and caregivers may be included with consent.
Job Description
Utilize best practice models to identify, incorporate, or develop panel‑management best practices.
Collaborate with other teams to share and establish best practices for health promotion and disease prevention strategies.
Manage assigned panel by addressing and resolving acute and chronic care needs through a team‑based approach.
Use electronic health records to track and monitor members’ follow‑up and health indicators.
Document care management functions—needs screening, comprehensive assessment, and care planning—in the care management platform.
Apply dashboards and population health tools for interventions and innovations to address care gaps.
Use NC Health Connects for information gathering and data collection.
Coordinate and follow up on referrals to outside specialty providers, recent ED visits, and ICC visits.
Coordinate and follow up on recent admissions and discharges.
Provide member education on health assessment, disease processes, medications, treatment plans, and community resources.
Assess member needs using established clinical guidelines, protocols, and pathways.
Collect data on biological, psychological, social, and cultural factors influencing health status and incorporate this data into member‑centered care plans.
Interpret data and recognize relationships between data and member’s health status to determine need for immediate interventions.
Initiate individualized care plans based on assessments, considering social determinants of health and human behavior while adhering to standards of care.
Develop individualized plans of care with input from the member, family, and others requested for high‑risk members.
Define expected member outcomes that are observable, time‑bound, and aligned with the member’s capabilities.
Assist in establishing a multidisciplinary care team for each member.
Coordinate closely with each member’s primary care provider, care manager extenders, county child welfare workers, EBCI Family Safety staff, CIHA Care Team, family members, and guardians.
Assume coordination responsibility for transition planning and provide best effort contact during inpatient psychiatric or hospital stays.
Provide transitional care management during care transitions, including from intensive treatment settings to foster care homes or community placements.
Obtain copies of discharge plans, review with member and facility staff, and facilitate clinical handoffs.
Ensure robust medication reconciliation and management; support medication adherence.
Direct extender care‑management functions and ensure allowable activities are performed.
Implement the Healthy Opportunities Pilot (HOP) program for HOP‑eligible members.
Facilitate additional requirements for members obtaining 1915(i) services.
Provide 24/7 support during emergencies or behavioral health crises when required.
Convene the care team at least twice per year and share the care plan/ISP with the team and other representatives.
Coordinate closely with county child welfare workers and EBCI Family Safety staff on transitional living plans.
Participate in required agency trainings, state trainings, and payor trainings within assigned timeframes.
Travel to community locations, agencies, and outreach destinations as necessary.
Maintain all certifications or licensure required for the position.
Demonstrate awareness and knowledge of agency policies, procedures, and regulatory requirements.
Meet minimum monthly contacts and effectively engage with members.
Participate in 24‑hour coverage for emergency medical conditions and behavioral health crises.
Be prepared for on‑call and callback duties and occasional work beyond standard hours.
Undergo annual evaluation of performance and problem‑solving skills.
Education, Licensure, Certification, and Experience
Meet North Carolina’s definition of a Qualified Health Professional per 10A-NCAC 27G.0104.
Qualified profesional within the mh/dd/sas system of care includes a registered nurse licensed in North Carolina with four years of full‑time experience in mh/dd/sa, or a graduate with a Master’s in a human service field and one year of full‑time supervised mh/dd/sa experience, or similar credentials for substance abuse professionals.
For LTSS needs: two years of prior LTSS/HCBS coordination experience in addition to above requirements.
Preferred experience working with Native Americans.
Current Basic Life Support (BLS) required; can be obtained within 6 months.
Valid North Carolina driver’s license.
Job Knowledge
Ability to plan, manage, and organize work to meet priorities within established time frames and under stressful conditions.
Understanding of multidisciplinary health care team functions.
Communication skills—strong interpersonal, written, and verbal.
Conflict management and resolution skills.
Proficiency in Microsoft Office (Word, Excel, Outlook).
Capability to master care‑management platforms and interpret data for decision making.
Diplomacy and discretion in negotiating and resolving issues independently.
Organizational skills to prioritize duties and meet deadlines with minimal supervision.
Working knowledge of special needs of members eligible for Tailored Care Management services.
Expertise in transition‑to‑adulthood systems and skills (accessing food, transportation, housing, employment, insurance options).
Utilization of motivational interviewing techniques and other engagement tools.
Additional Information Travel may be required. Some overnight travel may be necessary for meetings or training. The position supports a hybrid work model with flexibility for remote work.
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