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MHSU Care Manager - DSS Embedded

- Fulltime  

MHSU DSS Embedded Care Manager


The MHSU Care Manager (CM)- DSS, hereafter referred to as DSS CM, is a unique position within the Mental Health/Substance Use (MHSU) Care Management Team who is co-located at our local Department of Social Services (DSS).  This positions is responsible for all the MHSU Care Manager aspects as well as consultation, education, focused communication, and system navigation for DSS social workers.  


Provides proactive intervention and coordination of care to eligible members identified as Special Health Care Needs, Complex Care Management or High-Risk High Cost populations to ensure that these individuals receive appropriate assessment and services, with a focus on those members and families involved with DSS.  Works with the member and care team to alleviate inappropriate levels of care or care gaps through assessment, multidisciplinary team care planning, linkage and/or coordination of services across the MH/SU/IDD and other healthcare network(s) with existing or new care team members.  Supports clinical transition planning assistance to local hospitals and tracks individuals discharged from state and community hospitals to ensure they follow up with aftercare services and receive needed assistance to prevent further hospitalization.  Point of contact for supporting DSS emergency placement issues. 


This is a mobile position with work done in a variety of locations but primarily co-located with the local Department of Social Services and in members home communities. Essential job functions of the MHSU Care Managers include, but may not be limited to:  

  • CM Platform basics
  • Outreach & Engagement
  • Release of Information practices
  • Health Risk Assessment 
  • Medication List and Continuity of Care process
  • Care Planning
  • Interdisciplinary Care Team and Ongoing Care Management
  • Consultation with DSS
  • Education and System Navigation with DSS


*Must reside in North Carolina

Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.



 Consultation, Collaboration, System Navigation:

  • Coordinate and facilitate a shared case staffing with DSS social workers, behavioral health providers and Vaya care management in order to proactively plan for and communicate care needs.    
  • Provide clinical and administrative consultation for DSS social workers.
  • Provide system navigation for DSS social workers to understand and work within the behavioral health system.  Participate in DSS facilitied staffings to provide consultation and support.
  • Serve as a collaborative partner in identifying system barriers through work with community stakeholders.
  • Manage and facilitate Child/Adult Team meetings in collaboration with DSS, DJJ, CCNC, school systems, and other community stakeholders as appropriate.
  • Partner with other Vaya departments to address identified needs within the catchment. 
  • DSS CM may participate in cross-functional clinical and non-clinical meetings and other projects to support the department and organization.
  • Participate in routine multidisciplinary huddles including RN, Pharmacist, M.D. to present complex clinical case presentation and needs, providing support to other CCM’s and receiving support and feedback regarding CM interventions for clients’ medical, behavioral health, intellectual /developmental disability, medication, and other needs.
  • Participate in other high risk multidisciplinary complex case staffing’s as needed to include Vaya Chief Medical Officer, Deputy Chief Medical Officer, Utilization Management, Provider Network, and Care Management leadership to address barriers, identify need for specialized services to meet client needs within or outside the current behavioral health system.


 Clinical Assessment:      

  • Meets with members to conduct a comprehensive bio-psycho-social assessment in order to gather information on their overall health, including behavioral health, developmental, medical, and social needs.
  • Administer the PHQ-9, GAD, CRAFFT, ACES, LOCUS/ CALOCUS, and other assessments based on member’s clinical needs and scores are calculated and reviewed allowing CM to provide specific education and self-management strategies as well as linkage to appropriate therapeutic support.
  • Review and transcribe member’s current medication and entering into Vaya’s Care Management platform to ensure the medication aspects of the members health and care are addressed according to Vaya procedures.  
  • Ensure members of the care team are involved in the assessment as indicated by the member and other available clinical information is reviewed and incorporated into the assessment. 
  • Review clinical assessments conducted by providers to ensure all areas of the member’s needs are addressed.  


 Care Planning & Interdisciplinary Care Team:

  • Create a person-centered care plan for members to help define what is important to members for their health.
  • Assist members in refining and formulating treatment goals, identifying interventions, measurements, and barriers to the goals.
  • Partner with the integrated care team (i.e. RN and pharmacist) along with the member to address needs and goals in the most effective way and monitor progress.
  • Ensure Care Plans include specific services to address mental health, substance use or intellectual/developmental disability, medical and social needs as well as personal goals.
  • Ensure care plans are developed at least once a year or anytime there is a significant life change.
  • Ensure members/guardians have the opportunity to decide who they want at the care team meeting and coordinates and may facilitate the team meeting where member Care Plan is discussed and reviewed. 
  • Ensure the assessment, care plan and other relevant information is provided to the care team as indicated in Vaya policy. 

Other duties as assigned.



Bachelor's Degree in a field related to health, psychology, sociology, social work, nursing or another relevant human services area or licensure as an RN* (see licensure section) and the following experience:

  • Serving members with BH conditions: 
    • Two (2) years of experience working directly with individuals with BH conditions
  • Serving members or recipients with an I/DD or Traumatic Brain Injury (TBI)
    • Two (2) years of experience working directly with individuals with I/DD or TBI
  • Serving members with LTSS needs
    • Minimum requirements defined above
    • Two (2) years of prior Long-tern Services and Supports and/or Home Community Based Services coordination, care delivery monitoring and care management experience.
    • This experience may be concurrent with the two years of experience working directly with individuals with BH conditions, an I/DD, or a TBI, described above

OR, a combination of education and experience as follows:

Meet North Carolina’s Qualified Professional Definition:  graduate of a college or university with a bachelor's degree in a field other than human services and has four years of full-time, post-bachelor's degree accumulated MH/DD/SA experience with the population served, or a substance abuse professional who has four years of full-time, post-bachelor's degree accumulated supervised experience in alcoholism and drug abuse counseling. 


*Full-time Mental Health/Developmental Disabilities/Substance Abuse Services experience required for credentialing as a Qualified Professional may be obtained before or after obtaining the educational degree.



  • Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. 
  • Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. 
  • Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. 
  • Mental concentration is required in all aspects of work. 
  • Ability to drive and sit for extended periods of time (including in rural areas)



  • Familiar with Department of Social Services regulations and policies.  
  • Participate in and maintain Care Management and Vaya trainings and proficiencies as required.
  • A high level of diplomacy and discretion to effectively negotiate and resolve issues with minimal assistance.
  • Exceptional interpersonal skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts.
  • Problem solving, negotiation, arbitration and conflict resolution skills are essential to balance the needs of both internal and external customers.
  • Highly skilled at shifting between macro and micro level planning, maintaining both the big picture and seeing that the details are covered.
  • Extensive understanding of the Diagnostic and Statistical Manual of Mental Disorders (current version)
  • Knowledge of the MH/SU/DD service array provided through the network of Vaya providers.
  • Knowledge in Vaya Medicaid B and C waivers and accreditation is essential.
  • Detail oriented, able to organize multiple tasks and priorities, and to effectively manage projects through completion.
  • Ability to change the focus to meet changing priorities.
  • Exceptional communication skills, peer partnership, making appropriate decisions in high stress situations, being polite, respectful and assertive while maintaining positive relationships.  
  • Knowledge of standard office practices, procedures, equipment and techniques and have intermediate to advanced proficiency in Microsoft office products (Word, Excel, Power Point, Outlook, Teams, etc)
  • Understand the following areas, in addition to other required trainings:
    • BH I/DD Tailored Plan eligibility and services
    • Whole-person health and unmet resource needs (ACEs, Trauma, cultural humility)
    • Community integration (Independent living skills; transition and diversion, supportive housing, employment, etc)
    • Components of Health Home Care Management (Health Home overview, working in a multidisciplinary care team, etc)
    • Health promotion (Common physical comorbidities, self-management, use of IT, care planning, ongoing coordination)
    • Other care management skills (Transitional care management, motivational interviewing, Person-centered needs assessment and care planning, etc)
    • Serving members with I/DD or TBI (Understanding various I/DD and TBI diagnoses, HCBS, Accessing assistive technologies, etc)
    • Serving children (Child- and family-centered teams, Understanding of the “System of Care” approach)
    • Serving pregnant and postpartum women with SUD or with SUD history
    • Serving members with LTSS needs (Coordinating with supported employment resources


*If RN, licensure as an North Carolina RN (see education section)



In accordance with the BH and I/DD Tailored Plan requirements mandated by the NC Department of Health and Human Services, certain Vaya Health positions are required to be filled by individuals who reside in North Carolina, meaning someone who establishes a legal domicile in North Carolina and pays income tax in North Carolina, or resides within 40 miles of the North Carolina border. New hires from outside of North Carolina will have 60 days from the date of hire to meet this requirement, if applicable to the position.

This position is required to reside in North Carolina or within 40 miles of the North Carolina Boarder.