What are the responsibilities and job description for the Care Manager position at Southwest Montana Community Health Center?
Care Manager
Full-time, benefits-eligible
FLSA Non-exempt
Wage $17.00 DOE
Candidate review will begin 7/31 - Position open until filled
Candidate review will begin 7/31 - Position open until filled
Position Summary
Following the mission and vision of SWMTCHC, and under the general direction of the Outreach and Care Management Supervisor, this position is responsible for supporting an integrated care team and assisting patients/clients access integrated care services. Care Manager will collaborate with both internal and external service providers to assess patient/client needs, plan interventions, and coordinate services and resources essential to patient/client success. The Care Manager will adhere to high care standards, maintain confidentiality, and adhere to rigorous documentation requirements while supporting the patient/client’s dignity and right to self-determination.
Position Requirements
Education: Degree in social work, public health, human services, or related field preferred. Experience in these fields may be considered in lieu of education.
Experience: Prior experience in a healthcare setting or care management role preferred. FQHC experience highly preferred. Experience serving a diverse population including those who are vulnerable and/or may have high needs preferred. Previous EHR experience preferred.
Must be compassionate, empathetic, and sensitive toward individuals who are in a variety of socio-economic situations. Understanding of social determinants of health is
Job Requirements
- Provides confidential services to patients including screenings and referrals to resources, appointment scheduling, assistance with healthcare system navigation, assistance with insurance through Medicaid, Medicare, and the Affordable Care Act, and other ongoing support personalized to the patient’s needs
- Assists the care team by providing them with detailed communication about patient progress, serving as point-of-contact for other service agencies, providing population-focused support, participating in team meetings, and pre-visit planning
- Adheres to rigorous documentation procedures
- Operates a computer system and related software to complete work assignments
- Possess and apply the customer service skills necessary to effectively address the needs of the patients, regardless of special needs
- Must be compassionate, empathetic, and sensitive toward individuals who experience a variety of social determinants of health
- Apply knowledge in a manner that allows the needs of each patient to be met
- Follow SWMTCHC’s established policies and procedures including, but not limited to, tardiness, attendance, and time off requests
Essential Functions, Roles, and Responsibilities
Patient Identification, Intake, and Service
- Support Care Team through Pre-Visit Planning
- Work in conjunction with SWMTCHC providers and staff to provide efficient and high-quality direct services including:
Ø Patient needs assessments and/or screenings
Ø Referrals to appropriate resources with adequate support based on Social Determinants of Health
Ø Assistance with healthcare system navigation, including appointment scheduling
Ø Medicaid transportation coordination
Ø Goal planning and monitoring of patient centered care plans
Ø Follow-up and point of contact communication
Ø Warm hand-off visits with patients
Ø Providing a welcoming and supportive “medical home” connection
Ø Assisting patients in navigating Medicaid, Medicare, Healthcare for the Homeless and the Affordable Care Act
· Follows established policies and procedures regarding electronic health record (EHR) documentation of communication, visits, services provided, and plans for future care
· Follow requirements for documentation and patient services based on specific models of Care Management, such as Chronic Care Management, Transitional Care Management, Behavioral Health Integration, and more
· Maintain and continue expanding a knowledge base of community resources, evidence-based practices, effective screening tools, and healthcare system intricacies
· Provide taxi vouchers, clothing, food, personal hygiene products, and other essential commodities to patients with critical needs (typically for homeless and very high need patients)
· Daily internal referral reviews using the EHR and patient contact for appointment scheduling
· Relationship building with patients and their designated support network (family, friends, neighbors) to improve patient outcomes and service provision
· Monitor and respond to pager (device) and overhead paging for requests for Care Management services
Team Support and Service
· Facilitate communication with Care Team members on patient progress through face-to-face discussions, EHR messages/documentation, and team huddles/meetings.
· Participate in population health management through Collaborative meetings, departmental support, and specific “clinic” care
· Participate in Care Manager department meetings to facilitate communication, skill and knowledge advancement, workflow development, and other important aspects of job duties
Community Resource Collaboration
· Attend community-based meetings (as assigned) with representatives from external resources and services for information sharing, partnering, and targeting population health needs
· Maintain relationships and communication with representatives from external resources and services to facilitate patient access and to make appropriate referrals (i.e. Parent Partners, St. James Hospital, Continuum of Care, Hopa Mountain, and others)
· Accept and process some external referrals for patient care at SWMTCHC
Learning Responsibilities/Taking Direction
· Take responsibility to learn new position responsibilities as needed, including workflow changes and developments in technology
· Professionally take direction or re-direction on work performance and strive to improve performance as needed.
· Attend trainings and integrate training materials into work performance as approved by supervisor
Population Case Management
· Work in conjunction with SWMTCHC providers and staff to provide efficient and high-quality discharge planning for patients.
o Assessment/coordination for patients needing follow up appointments at SWMTCHC.
o Transitional planning/liaison for patients discharging from the hospital to transitional care/long term care.
o Transitional planning/liaison for patients discharging from the transitional care to home setting.
· Schedule medication reconciliation with Clinical Pharmacist
· Perform Social Determinants of Health (SDOH) questionnaire and provide patients with families with adequate resources
· Provide targeted case management to patients identified by the team
· Assess all new patients for SDOH & introduce Team-based Care model
· Perform SDOH screening as needed and at least annually for each patient
Miscellaneous Duties
· Under the direction of the provider, act as liaison with SWMTCHC staff, facilities, and patient’s family members
· Ask for help from others as needed
· Use courteous and professional language, tone, and body posturing, at all times
· Maintain a calm, respectful demeanor in all team and patient contact
· Complete unusual occurrence/incident reports per SWMTCHC policy and procedure
· Arrange scheduling and coverage for lunch or meeting attendance, prioritizing having at least one Care Manager available for patient care in the clinic, at all times
· Keep other team members informed of whereabouts when out of the clinic during work time
· Request time off in a timely manner in accordance with SWMTCHC policy
· Other duties as assigned
Knowledge, Skills and Abilities
- Competency in dealing with diverse populations; particularly with high need and/or vulnerable populations
- Ability to work independently and as a member of a team
- Excellent oral and written communication skills
- Ability to keep all stakeholders “in the loop” with relevant issues
- Ability to operate a computer, job related software, and various common office machines
- Ability to organize and prioritize tasks
- Strong attention to detail and problem-solving skills
- Ability to work under pressure
Legal Concepts
- Works within the scope of education, training, job description, and personal capabilities
- Maintains confidentiality
- Follows federal, state, and local legal guidelines; particularly as they relate to vulnerable populations and healthcare systems
- Maintains HIPAA & OSHA compliance
- Reports any evidence of abuse or neglect of individuals to provider and appropriate officials, with supervisor’s guidance
Supervision: This position has no supervisory responsibilities
Immediate Supervisor: Outreach and Care Management Supervisor
Physical Demands/Working Conditions:
General office/clinic conditions are pleasant; good, clean working conditions where accident and hazards are negligible; requires short periods of moderate lifting, pushing or pulling objects up to twenty pounds. Clear diction and acute hearing are necessary for effective communication with the staff and public.
This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change, or new ones may be assigned at any time with or without notice.
Southwest Montana Community Health Center is an Equal Opportunity Employer
Salary : $17
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