Care Manager

Working title: Care Manager

Classification title: Care Manager

Division: Main Clinic

Program: Care Management

Reports to: Care Management Services Manager

FLSA status: Non-Exempt:

Schedule: Monday-Friday; 8am-5pm

Wage Range: $21.50 to $27.37 hourly; depending on number of years of transferrable experience and internal equity

Organizational Overview

Serving the Yellowstone County community and south-central Montana for nearly 50 years RiverStone Health is an essential provider of personal and public health services. Health Education Leadership and Protection HELP is what we do.

From medical dental and behavioral healthcare; home care and hospice; public health services like immunizations WIC health promotion and restaurant inspections; and educating the next generation of health professionals our expertise spans all ages and stages of life. Underlying principles of access affordability compassion and quality in all interactions RiverStone Health improves life health and safety for all of the communities we serve.

Division and Program Overview:

Coordinates monitors and works closely in conjunction with the Patient Care Team in a Patient Centered Medical Home model to ensure effective quality and coordination of services. Managing patient care is a team effort that involves clinical and nonclinical staff (e.g. physicians nurse practitioners physician assistants nurses medical assistants educators front desk staff schedulers etc) interacting with patients to achieve stated objectives.

Job Summary:

The Care Manager position will provide care management to high-risk patients who are at risk for poor health outcomes and provide Care Management for those patients. The Care Manager will act as a member of the Patient Care Team to identify barriers to care and to understand the interplay between physical health mental health social issues and resource needs. This position encourages patients to actively engage in their own health and work toward maintenance or improvement of health status by creating care plan objectives.

Essential Functions/Major Duties and Responsibilities:

A. Care Manager Duties 95%

• Provides Care Management to patients by identifying high risk patients who are likely to benefit from effective care management using criteria applied to the patient population or by patient referral by any member of the patient care team.

• Performs patient assessment and develops individual care plans. Care Plan documentation includes evaluating the patients medical psychological social financial and educational/employment history any history of substance abuse and any services currently being received by the patent.

• Maintains active caseload and conducts multiple follow-up calls to monitor patient symptoms provide patient education and work on patient goals.

• Work with each patient to identify individualized clinical and personal healthcare goals such as improving therapeutic outcomes. Works to set and document attainable long and short term goals for individual progress.

• Ensure that patients have access to primary medical and dental services by assisting them with understanding the role of a primary care provider general health insurance terminology and how to appropriately use health coverage options.

• Coordinate communication between patients family members medical staff administrative staff or regulatory agencies.

• Respond to patients questions and comments in a courteous and timely manner.

• Explain policies procedures or services to patients using medical or administrative knowledge.

• Identify and refer clients to appropriate community resources and programs.

• Reviews patient medical records regularly and follows up with outside care providers agencies and community service providers to ensure that the patient receives appropriate assistance.

• Track patient outcomes using established outcome measures; design and implement strategies to improve outcomes

• Educate and assist individuals to enroll in Health Insurance Marketplace Medicaid Healthy Montana Kids and other insurances.

• Significant knowledge of community resources services and programs available to assist clients.

• Acts as an advocate for the patient within the patient care team and other community support services and organizations.

• Provides support to and utilizes motivational interviewing techniques to guide patients in following treatment plans and achieving life goals.

• Maintains proficiency in computer skills to include eCW email word excel programs. Utilize an electronic medical record to retrieve patient information and to develop and enter patient data into a computer database and/or spreadsheet.

• Accurately and appropriately document patient information in a timely manner and in accordance with RiverStone Health Clinic policies and procedures.

• Use logical and creative thought processes to develop solutions according to written specifications and/or oral instructions.

• Provide support to Satellite Clinics as requested

Non-Essential Functions/Other duties as assigned 5%

• Keep immediate supervisor and designated others accurately informed concerning work progress including present and potential work problems and suggestions for new or improved ways of addressing such problems.

• Perform other duties as assigned in support of RiverStones mission and goals.

Education and Experience:

Minimum Qualifications

• High School diploma or equivalent

• Experience in a social work or medical setting or any combination of experience and training which provide the equivalent scope of knowledge skills and abilities necessary to perform the work.

Preferred Qualifications:

• Bachelors Degree in social work sociology human services psychology or closely related field

Required Certificates Licenses Registrations:

• Valid Montana drivers license

Knowledge Skills and Abilities:

• Knowledge and understanding of protected sensitive patient health information (HIPAA) and confidentiality

• Ability to work collaboratively and maintain a positive work environment

• Ability to maintain a calm and positive demeanor during difficult client/patient interactions

• Ability to display non-judgmental and empathetic listening skills

• Ability to demonstrate cultural sensitivity when providing care and services to patients maintain awareness of social and/or medical issues and a willingness to work with underserved under- or un-insured and low-income patients treating each with dignity and respect

• Ability to communicate effectively with others both orally and in writing using both technical and non-technical language as appropriate to the situation.

Customer Service Excellence:

• Doing things right the first time

• Making people feel welcome

• Showing respect for each customer

• Anticipating customer needs and concerns

• Keeping customers informed

• Helping and going the extra mile

• Responding quickly

• Protecting privacy and confidentiality

• Demonstrating proper telephone etiquette

• Taking responsibility for handling complaints

• Being professional

• Taking ownership of your attitude toward Service Excellence.

Supervision:

• This position does not have supervisory authority

Physical Demands and Working Conditions:

• Frequent standing bending sitting lifting required

• Frequent customer interaction via telephone

• May travel between outreach clinic sites within the Billings community

• Create and maintain a safe/secure working environment by adhering to safety security and health requirements. Integrates injury illness and loss prevention into job activities by attending any necessary training and implementing best practices.

Freedom to Act & Decision Making:

• Ability to manage multiple tasks throughout the day and ensure tasks are completed in a timely manner.

• Ability and willingness to quickly learn and put to use new skills and knowledge brought about by rapidly changing information and/or technology.

• Ability to organize day to day responsibilities independently with assistance from Care Management team and/or Care Management Services Manager as needed.

Communications & Networking:

• Daily written and verbal communication with patients and their families co-workers and community partners.

• Maintain HIPPA compliant records and communication.

Budget & Resource Management:

• No budgetary authority.

Required Experience:

Manager