CSFP Care Manager - $5,000 Hiring Bonus

Company: Cherokee Indian Hospital Authority
Location: Cherokee
Posted on: April 23, 2025

Job Description:

Job Title: CSFP Care Manager

Job Code: CSFP CM

Department: Tribal Option/ Primary Care

Division: Nursing/Tribal Option

Salary Level: Non-Exempt 12

Reports to: CSFP Care Management Supervisor

Last Revised: August 2024

Primary Function

The CFSP(Children and Families Specialty Program) aims to improve the health and

well-being of children, youth and families served by the child welfare system. The

CFSP design emphasizes a family-focus and seeks to:
--- Improve members' near- and long-term physical and behavioral health

outcomes.
--- Increase timely access to physical health, behavioral health, pharmacy, LTSS

and I/DD providers with experience serving children with high acuity needs,

as well as unmet health-related resource needs.
--- Strengthen and preserve families, prevent entry and re-entry into foster care,

and support reunification and other permanency plan options.
--- Coordinate care and facilitate seamless transitions for members who

experience changes in treatment settings, child welfare placements, transitions

to adulthood, and/or loss of Medicaid eligibility.
--- Improve coordination and collaboration with county DSS agencies, EBCI

Family Safety Program, and more broadly, with Community Collaboratives -

a comprehensive network of community-based services and supports

leveraging a system of care approach to meet the needs of families who are

involved with multiple child service agencies.
--- Provide services that meet children's behavioral health needs and prevent

children from boarding in county DSS agency offices and Emergency

Departments.

For Members that have Tailored Care Plan eligibility, the incumbent is responsible for

those aspects of care for that member.

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Job Description
--- Utilizes best practice models to identify, incorporate or develop best practices for

panel management. Collaborates with other teams to share and establish best

practice for health promotion and disease prevention strategies.
--- Manages panel by addressing and resolving acute care needs and chronic care

needs through a team based approach.
--- Utilizes iCare to track, monitor, and assure the appropriate follow-up of clients

targeting specific indicators.
--- Utilizes the care management platform for documentation of care management

functions such as a care needs screening, Comprehensive assessment, and care

planning. Also utilizes the dashboards, within the care management platform for

population health and related interventions and innovations
--- Utilizes NC Health connects for information gathering and data collections for

management of care needs or gaps in care
--- Coordinates and follows up on referrals to outside specialty providers, recent ED

visits, and ICC visits. Emphasis is placed on ensuring treatment notes are

available to the PCP timely.
--- Participates in the continued development of the role of Case Management in the

Patient Centered Medical Home (PCMH) and Advanced Medical Home (AMH).
--- Promotes health care outcomes with currently accepted clinical practice

guidelines.
--- Provides patient education, advice and information on health assessment, disease

processes, medications, treatment plans and available community resources.
--- Assesses patient needs using established clinical guidelines, protocols, and

pathways.
--- Provides appropriate follow up as directed or per established guidelines.
--- The incumbent will be evaluated annually on his/her ability to identify, assess,

analyze, and evaluate data and solve problems through the CIH Performance

Appraisal System.
--- Collects data from relevant sources (patient, family, or caregiver) regarding the

biological, psychological, social and cultural factors that might influence and

impact the health status of the individual and utilizes this data in patient center

care plan development.
--- Collects data through observations of appearance and behavior, measurements of

physical structure and physiological function, and other information in an effort to

place consultations and/or referrals to the correct internal and external resources

(Nutrition, Tsali Manor, etc.).
--- Interprets data and recognizes existing relationships between data collected and

the client's health status and treatment regimen and determines the client's need

for immediate nursing interventions.
--- Reviews the patient's health records and health summary, interviewing patients

and family members, documenting the chief complaints, medical history, physical

and clinical findings, identifying learning needs of the patient and family, and

determining priority of care required. Assessment for health prevention, health

promotion, restorative, and health maintenance needs is emphasized.

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--- Will plan patient care according to individual assessed patient needs and

established hospital policies and procedures.
--- Develops individualized plan of care with input from the patient, patient's family,

care team members, and anyone else the patient requests to be included for those

patients considered "high risk."
--- Initiates individualized care plan based on assessment of the patient for specific

illnesses, injuries, and diseases Social Determinants of Health (SDoH) and human

behavior while adhering to appropriate standards of care.
--- Develops expected patient outcomes that are observable and within an adequate

period, and are congruent with the patient's present and potential physical

capabilities and behavioral patterns.
--- Assumes coordination responsibility for transition planning.

o Use of ADT including high risk ADT Alerts:
--- Real time (within minutes/hours) response to notifications of ED

visits.
--- Same-day or next-day outreach for designated high-risk subsets of

the population; and
--- Additional outreach within several days after the alert to address

outpatient needs or prevent future problems for other patients who

have been discharged from a hospital or an ED (e.g., to assist with

scheduling appropriate follow-up visits or medication

reconciliations post-discharge).
--- May be required to change work schedule to assist in covering for periodic "late

clinics."
--- Coordinates closely with each member's primary care provider (PCP), and, as

appropriate, care manager extenders, assigned County Child Welfare worker,

EBCI Family Safety Program staff, CIHA Care Team, family members and

guardians to manage the member's health care needs throughout their time

enrolled in the CFSP.
--- Directs the extender's care management functions and ensure that the extender

supports allowable activities (e.g., coordinating services/appointments by

arranging transportation, etc.).
--- Conducts a care management comprehensive assessment for each member
--- Develops a care plan (for members without I/DD and TBI needs) or an individual

support plan (ISP) (for members with I/DD and TBI needs).

o The care plan/ISP will provide a blueprint for ongoing care management

and include the member's health, social, emotional, educational and other

service needs and relevant permanency planning information from the

member's assigned County Child Welfare worker or EBCI Family Safety

Program staff as applicable, among other elements.

o For members receiving treatment in a congregate setting (e.g., group home

or PRTF), the member's care plan/ISP will also identify the needed

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services, supports, and timeline to facilitate the member's transition to a

family-based placement, as clinically appropriate.

o Include standard timelines that care managers must meet for administering

care management comprehensive assessments and developing each

member's care plan/ISP; the required timelines will differ for members

identified as high-risk compared to members not identified as high-risk.

o Delivery of the care management comprehensive assessment and

development of the care plan/ISP must be accelerated, as needed, to

manage members' urgent needs/crises.
--- May be required to provide 24/7 support during emergencies or behavioral health

crises, including working with County Child Welfare workers (or EBCI Family

Safety Program staff) to secure immediate treatment services, as needed.
--- Responsible for establishing a multidisciplinary care team for each member.

o For children, this multidisciplinary care team might include but is not

limited to the member, the member's assigned care manager, parent(s),

guardian(s), or custodian(s) (as appropriate), the County Child Welfare

worker, care manager extenders, and the member's PCP.

o For adults, the multidisciplinary team might include but is not limited to

the member's assigned care manager, the County Child Welfare worker,

care manager extenders, and the member's PCP.
--- Responsible for convening the care team on a regular basis (no less than twice per

year, and more often, as appropriate) and will share the care plan/ISP with the

member's care team and other representatives, as appropriate, to support delivery

of the member's needed health and health-related services.
--- Required to coordinate closely with each member's assigned County Child

Welfare worker

o For CFSP members who are served by the EBCI Family Safety Program

instead of NCDSS or county DSS agencies, the CFSP will be required to

coordinate with EBCI Family Safety Program staff in place of County

Child Welfare workers.
--- Meet and coordinate with County Child Welfare workers (or EBCI Family Safety

Program staff) to:

o Share relevant health and health-related information, as permitted, and

coordinate strategies to address members' health and social needs to

support and promote family preservation, permanency planning and

reunification, as applicable

o Assist with scheduling NCDSS-required health assessments, gathering

medical records, and developing a crisis plan. Identify health and health

related services that are necessary to support family preservation for

families receiving CPS In-Home Services and reunification or other

permanency planning efforts for children in foster care and their families

o Obtain consent for treatment of certain health care conditions from a

member's parent(s), guardian(s), or custodian(s), unless there are

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restrictions regarding such communication (e.g., termination of parental

rights or court order restricting communication) in accordance with

applicable North Carolina state law.
--- Provides transitional care management during care transitions (including assisting

individuals with transitioning from congregate or other intensive treatment

settings to a foster care home or other community placement).

o notify the County Child Welfare worker or EBCI Family Support Safety

Program staff, as appropriate, and parents(s), guardians(s) and

custodian(s), as appropriate, of a change in health plan and assist in

selecting a new PCP, if necessary.

o required to connect with the member before and after discharge, conduct

discharge planning, facilitate clinical handoffs and arrange for medication

reconciliation and management following discharge from a hospital or

institutional setting or following an emergency department visit.
--- Collaborate with County Child Welfare workers as needed in the development of

the NCDSS-required transitional living plan and 90-day transition plan.

o identify key health-related resources and supports necessary to achieving

the member's health care goals

o developing a Health Passport for each member as a supplement to the

90day transition plan.
--- The Health Passport is a document, available electronically and in

paper formats, which will contain critical health care-related

information, such as upcoming scheduled visits, prescribed

medications and the member's medical records.
--- educate members about potential Medicaid and alternative

insurance options available to them (e.g.,

Marketplace/Qualified Health Plan (QHP) coverage,

applicable EBCI tribal programs/funding options, etc.) and

assist them in signing up if desired, for former foster youth

aging out of the Medicaid for Former Foster Care

categorical Medicaid eligibility group
--- transitioning all ongoing health care services and

medications. The Health Passport for these members must

also include a list of health care resources available to

members regardless of insurance status.
--- Responsible for ensuring members receive robust medication reconciliation and

management. This will include, at minimum, medication reconciliation and

management following health care and other life transitions (including placement

changes), assistance with refilling medications, and leveraging CFSP clinical staff

(e.g., psychiatrist) to assess the clinical appropriateness of members' medication

regimens.
--- Responsible for implementing the Healthy Opportunities Pilot (HOP) program for

its HOP-eligible members,

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--- May be subject to on-call and callback.
--- Evaluates patient care provided.

- Directly observes and evaluates patient care.

- Revises nursing care and care plans to reflect changes in patient needs.

- Documents nursing care and patient progress according to hospital policy.

- Participates in ongoing nursing quality assurance program.
--- May be necessary to work when Administrative leave is granted if patient care

would be compromised.

Education, Licensure, Certification, and Experience
--- A bachelor's degree and Five years of experience providing care management,

case management, or care coordination to complex individuals with CSFP or

foster care; or
--- A master's degree in a human services field and Three years of experience

providing care management, case management, or care coordination to complex

individuals with CSFP or foster care.
--- If a RN, applicant must have an unrestricted valid Registered Nurse license within

the state of North Carolina or a state that is accepted as reciprocity.
--- Current Basic Life Support (BLS) minimally required. Can be acquired through

the facility within 6 months following appointment to position.
--- Specific experience working with Native Americans preferred.
--- Applicant must have a valid North Carolina driver's license.

Job Knowledge
--- Knowledge and ability to independently plan, manage, and organize work in order

to meet priorities, accomplish work within established time frames and work in

stressful situations.
--- Knowledge of the occupational functions of multi-disciplinary health care team.
--- Knowledge of the culture and medical health profile of the patient population.
--- Knowledge and ability to teach and counsel patient/family on health maintenance

and disease prevention.
--- Knowledge of available health care programs and community resources.
--- Knowledge of problem oriented medical record methods.
--- Knowledge of care management including screenings, assessments, development

of care plans and knowledge of resources available to members at all levels

including tribal, county, regional and state.

o In addition, have a working knowledge of the special needs of members

who fall into the category of being eligible for Tailored Care which

includes those members with care needs related to a behavioral health

condition (including both mental health and substance use disorders),

intellectual/developmental disability (I/DD), or traumatic brain injury

(TBI).
--- Knowledge is required of and to have expertise in the systems and tools that are

fundamental to the transition to adulthood, including independent living skills

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(e.g., accessing food and transportation), post-high school education, housing and

employment options, self-advocacy, health insurance coverage options after

Medicaid eligibility ends and building natural supports.
--- Knowledge of ISP/Care Plan development and implementation for members of

EBCI Tribal Option (TO) that are tailored plan eligible including the following:

o Responsibility of the six core Health Home Services for the tailored plan
--- Comprehensive care management
--- Completion of care management comprehensive

assessments and care plan/ISP
--- Phone call or in-person meeting focused on chronic care

management (e.g., management of multiple chronic

conditions)
--- Care coordination, including
--- Working with the member on coordination across settings

of care and services (e.g., appointment/wellness reminders

and social services coordination/referrals)
--- Assistance in scheduling and preparing members for

appointments (e.g., phone call to provide a reminder and

help arrange transportation)
--- Health promotion, including
--- Providing education on members' chronic conditions
--- Teaching self-management skills and sharing self-help

recovery resources
--- Providing education on common environmental risk factors

including but not limited to the health effects of exposure

to second- and third-hand tobacco smoke and e-cigarette

aerosols and liquids and their effects on family and children
--- Comprehensive transitional care/follow-up, including
--- Visiting the member during the member's stay in the

institution and be present on the day of discharge
--- Reviewing the discharge plan with the member and facility

staff
--- Referring and assisting members in accessing needed social

services and supports identified as part of the transitional

care management process, including access to housing
--- Developing a 90-day post-discharge transition plan prior to

discharge from residential or inpatient settings, in

consultation with the member, facility staff, and the

member's care team
--- Individual & family support, including
--- Providing education and guidance on self-advocacy to the

member, family members, and support members

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--- Connecting the member and parents/other family

members/caregivers to education and training to help the

member improve function, develop socialization and

adaptive skills, and navigate the service system
--- Providing information to the member, family members, and

support members about the member's rights, protections,

and responsibilities, including the right to change

providers, the grievance and complaint resolution process,

and fair hearing processes
--- Referral to community & social support services, including
--- Providing referral, information, and assistance and follow up in obtaining and maintaining community-based

resources and social support services
--- Providing comprehensive assistance securing key health related services (e.g., filling out and submitting

applications)
--- 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 MH/SUD, and waiver benefits plans
--- Knowledge of and skilled in the use of Motivational Interviewing and techniques
--- Strong interpersonal and written/verbal communication skills
--- Conflict management and resolution skills
--- Proficient in Microsoft Office products (such as Word, Excel, Outlook, etc.)
--- Ability to master care management platforms and review data for decision making

and person-centered planning
--- 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
--- Good organizational skills to prioritize duties and work with minimal levels of

onsite supervision to consistently meet deadlines

Complexity of Duties

Complies also with federal, state, accrediting and local regulations. These guidelines are

not always specifically applicable to the individual patient or situation and independent

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judgment is required in selecting the most appropriate guideline, and applying the intent

of the guideline to the specific situation at hand.

Supervision Received

The nurse independently plans, schedules, and provides nursing care in coordination with

the medical care plan and attempts to solve problems only within established procedures.

This is done under the supervision of the CSFP Care Management Supervisor and

Assistant Director of Care Management. The work is evaluated for technical soundness

and adherence to professional standards.

Responsibility for Accuracy

The incumbent has a positive effect upon the recovery of the patient and is responsible

for following policies and procedures, which serve as hospital guidelines and prevents

errors from occurring. Errors can have a negative patient outcome since the incumbent's

performance affects the health, recovery, and rehabilitation of patients, and the quality of

care provided. Evaluations and observations are used to modify and develop clinically

appropriate treatment plans. Work can be verified or checked by the immediate

supervisor, other health care providers or systems checks, but usually the responsibility

for accuracy relies solely on the incumbent.

Contacts with Others

Contacts are with patients, families, hospital personnel, and community agencies.

Contacts with patients, families, and hospital personnel are to exchange, provide, and

obtain information concerning the patient's physical and psychosocial health care

problems, and needs. The nurse uses teaching and counseling methods to influence and

motivate patient and family behavior. Contacts with other health care or related

disciplines within the hospital are for the purpose of collaboration and consultation. Tact,

courtesy, and professional conduct are required to maintain positive working

relationships. Utmost sensitivity and confidentiality is required when dealing with

patients and families.

Confidential Data

The incumbent has access to highly confidential patient medical and personal

information. The Privacy Act of 1974 mandates that the incumbent shall maintain

complete confidentiality of all administrative, medical, and all other pertinent

information that comes to his/her attention or knowledge. The Act carries both civil and

criminal penalties for unlawful disclosure of records. Violations of such confidentiality

shall be cause for adverse action.

Mental/ Visual/ Physical

Work in the various services within the nursing department is mostly sedentary, yet

requires walking, standing, bending, pushing, and lifting in helping patients to and from

beds, wheelchairs, and stretchers. These same activities are required in moving

equipment and medical supplies. Will be subject to frequent interruptions requiring

varied responses, which can cause distractions therefore, the incumbent must possess the

ability to differentiate and prioritize many tasks at once.

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Work Environment

Must be flexible in working hours. Work is performed in the clinic setting, which is

responsible for treating patients with a wide variety of medical problems. Incumbent may

be exposed to communicable diseases. Incumbent is required to comply with Employee

Health Program guidelines including current immunization status of identified

communicable diseases and safety precautions are sometimes necessary, such as use of

personal protective equipment as required by hospital policy. The work environment

involves moderate risks of exposure to infectious disease, radiation, electrical hazards,

irritant chemicals and explosive gases.

Customer Service

Consistently demonstrates superior customer service skills to patients/customers by

demonstrating characteristics that align with CIHA's guiding principles and core values.

Ensure excellent customer service is provided to all patients/customers by seeking out

opportunities to be of service.

Keywords: Cherokee Indian Hospital Authority, Knoxville , CSFP Care Manager - $5,000 Hiring Bonus, Executive , Cherokee, Tennessee