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Tailored Care Management Practice Support Coach

2131 South 17Th Street
Wilmington, NC
Job ID: 4225
Date Posted: Oct 22, 2021

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Job Description



NHRMC, established in 1967 in Wilmington, NC, is recognized as a preeminent healthcare organization focused on leading our community to outstanding health. We have an 855 bed network of hospitals and multi-specialty physician group practices with more than 200 physicians. With a network of primary, specialty, neighborhood clinics and regional medical centers; you will find our culture is the very definition of best in practice. Join us and find out how many ways NHRMC offers you the chance to focus on what really matters - our patients and community.

About the Job

Location: New Hanover Regional Medical Center

Department: Practice Support Services

Full Time Equivalent: FTE: 1.000000

Work Type: 64 to 80 Hours Pay Period

Work Schedule: STD HRS - Standard-Exe or Office w flex

Exempt from Overtime: Exempt: Yes

What You'll Do


The AHEC Tailored Care Management Practice Support Coaches (TCM PS Coaches) work within the nine, regional NC AHEC Area Health Education Centers (AHECs) under the Practice Support service line to consult and provide one-to-one coaching, including scheduled, weekly, “on the ground” training and direction to multiple behavioral health, intellectual and developmental disability (I/DD) and primary care/specialty physician practices in urban and rural areas statewide to enable them to thrive in the Tailored Care Management model. Specific focus of work will be providing technical assistance to Advanced Medical Home Plus (AMH+) organizations and Care Management Agencies (CMAs) for Tailored Care Management (TCM) for behavioral health, I/DD, Traumatic Brain Injury (TBI), Innovations Waiver, Substance Use Disorder (SUD) and co-occurring disorders in the North Carolina Medicaid Behavioral Health I/DD Tailored Plan. Technical assistance will include all clinical and operational needs of the AMH+s/CMAs including the adequacy and effective use of clinical consultants and building relationships with health-related and social support providers, as required by the TCM model. During the COVID-19 state of emergency, practice support visits from the TCM PS Coaches and the TCM PS Coordinator to AMH+s/CMAs will be in-person, virtual or telephonic, as is necessary for the goals of TA and appropriate to protect the safety of staff during the TA. These practice visits will also include additional support from statewide subject matter experts, as needed. TCM PS Coaches will be assigned by LME/MCO service catchment areas as needed. Based on the distribution of AMH+s and CMAs across the state, TCM PS Coaches may be required to support practices that are outside the regional boundaries of their home AHEC. Best efforts will be made to keep TCM PS Coaches as close as possible to their home AHEC regions, limit extensive travel and make web-based coaching support available to practices when appropriate. The TCM Practice Support Coaches will report directly to their regional AHEC Practice Support Director/Team Lead and will be supervised by a dedicated full-time Tailored Care Management Practice Support Coordinator (TCM PS Coordinator), who has subject matter expertise in care management, behavioral health integration, and primary care practice support. The TCM PS Coordinator will meet with the statewide team of TCM PS Coaches via a web-based platform (i.e. GoToMeeting, WebEx, Microsoft Teams, etc.) at least twice a month for scheduled consultation, to review projects/performance and provide updates about TCM-related work. Ad hoc consultation and supervision will also be provided by the TCM PS Coordinator to the TCM PS Coaches. TCM PS Coaches will also participate in twice a month learning collaborative trainings with AMH+s/CMAs, the TCM PS Coordinator, other SMEs and the Tailored Care Management Collaborative (TCMC) at MAHEC on topics related to TCM. 


1. Meet with providers and staff within assigned caseload to: Assess practices’ capacity and readiness to improve by: o Surveying practices’ current state to provide best-practice technical assistance for Tailored Care Management (TCM) with Advanced Medical Home Plus (AMH+) primary care organizations and Care Management Agencies (CMAs) serving Medicaid beneficiaries with behavioral health, Intellectual/Developmental Disability (I/DD), Traumatic Brain Injury (TBI), Innovations Waiver, Substance Use Disorder (SUD) and co-occurring disorders. o Introducing planned, structured approaches to improving care through use of the gap analysis tool created by NC AHEC and approved by NC Medicaid prior to assessment of AMH+s and CMAs. 2. Meet with providers and staff within assigned caseload to teach practices to: o Meet Tailored Care Management requirements of AMH+ and CMA agencies within the NC Medicaid Behavioral Health and Intellectual/Developmental Disability (BH I/DD) Tailored Plan. o Prioritize and plan improvement activities and projects. o Measure tailored care they provide to patients. o Measure health status of their patients at the population level and adopt practice-specific guidelines for Tailored Care Management, behavioral health integration and chronic condition care based on evidence and/or expert consensus. o Measure patient and family experiences of care. o Use data as the basis for practice improvement. o Analyze workflows. 3. Meet with providers and staff within assigned caseload to: Identify programs that recognize and reward practice improvement for which a practice may be eligible. o Develop and maintain project plans for assigned practices for all initiatives related to program funding sources. 4. Follow training and practice guidelines outlined by grants, NC AHEC’s program office, and the TCM PS Coach’s regional AHEC. 5. Actively participating with the Practice Support team of the TCM PS Coach’s regional AHEC by: o Attending regular team meetings. o Attending regular huddles with the Director of Practice Support. o Contribute to the agenda and training at team meetings. 6. Supporting Tailored Care Management Practice Support efforts at the state level will include, but is not limited to: o Assisting with the development of ongoing education related to Tailored Care Management (comprehensive care management assessment, development of care plans/individual support plans/care teams, developing and formalizing relationships with community-based health-related and social supports providers, Healthy Opportunities, NC Care 360, NC HIEA, NC Medicaid Transformation). o Attending and participating in listservs, training meetings, conference calls and web-based programs as needed. o Working with the statewide team of Tailored Care Management Practice Support Coaches, the Tailored Care Management Practice Support Coordinator and the Tailored Care Management Collaborative at Mountain AHEC to identify and develop written resources, educational programs and reports. o Serving as a liaison when needed between the practices, the TCM PS Coach’s regional AHEC, NC AHEC Program Office, and others as designated. o Presenting oral or written information about the statewide Tailored Care Management Practice Support activities at statewide meetings. o Sharing documentation of site visits, assessments, tools or materials developed and used within practices. 7. Supporting regional and statewide Continued Professional Development (CPD) efforts by: o Monitor the marketplace and communicate to Continued Professional Development current trends, needs, and emerging modalities in the delivery of healthcare education. o Identifying educational needs at the practice and community level to plan, coordinate, and provide continued professional development for healthcare professionals and constituents. o Work closely with the TCM PS Coach’s regional AHEC Director of Practice Support and Director of Continued Professional Development to provide direct support to those practices that need assistance with implementing quality improvement projects and to implement practice-based continuing education activities related to quality improvement. 

Position Requirements


* Bachelors Degree
* Masters Degree

Other information:

Education: Required: A bachelor’s degree in a field related to health, psychology, sociology, social work, nursing or another relevant human service area; Preferred: Master’s degree in a field related to health, psychology, sociology, social work, nursing or another relevant human service area, or licensure as a registered nurse (RN). 

Licensure / Certifications: Required: None; Preferred: Licensure or working towards licensure with “Associate” or “Provisional” level issued in a behavioral health field (Licensed Clinical Social Worker (LCSW or LCSWA), Licensed Clinical Mental Health Counselor (LCMHC or LCMHCA ), Licensed Psychological Associate (LPA/LPA Provisional), Licensed Marriage and Family Therapist (LMFT/LMFTA), or licensure as an RN) is a plus. NAHQ Certified Professional in Healthcare Quality is a plus. NCQA Patient Center Medical Home Certified Content Expert is a plus. 

Experience: Required: Two years of care management experience working directly with individuals with behavioral health conditions (Adult, Adolescent & Child), I/DD, Substance Use Disorder (SUD), TBI, Innovations Waiver, co-occurring disorders or serving members with Long Term Services & Supports (LTSS) needs and/or Home & Community Based Services (HCBS) coordination, care delivery monitoring, and care management experience; Preferred: Working knowledge of various behavioral health integration models. Experience working on quality improvement initiatives like Meaningful Use, Quality Payment Program-MIPS, Patient Center Medical Home, or healthcare project management. 

Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence. Performs other duties as assigned. Individual will possess commensurate combination of education, experience and qualifications.

Other Information

This position description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications which may be required of the employee assigned to the position. Depending on the location of the job, duties may vary. Receipt of the job description does not imply nor create a promise of employment, nor an employment contract of any kind; my employment with the Company is at will.

  • Member Top 100 Hospitals – In 2016 NHRMC was recognized as a Top 100 Hospital demonstrating significant investment and financial sustainability for the communities we serve. 
  • Newsweek's 2020 list of Best Maternity Care Hospitals - NHRMC Betty H. Cameron Women's & Children's Hospital was named as a Best Maternity Care Hospital by Newsweek. 
  • Forbes America’s Best Large Employers 2018 and 2019Link 
  • Becker’s 150 Top Places to Work in HealthcareLink 
  • Healthgrades Outstanding Patient Experience

Consider a career at NHRMC and become part of this award winning team!

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