Care Manager - RN, CMA, LPN or LSW

About the position

The Care Manager is a key member of the medical home team, using registries and evidenced-based guidelines to drive the proactive care process for clinic patients. The role of Care Manager is to facilitate communication, coordinate services, address barriers, and track the health of the patient population assigned to a provider panel in accordance with the goals and mission of Family Health Services. This position can be full or part time, depending on the employee's needs. Hours per week will range from 24-40.

Responsibilities

• Participates in the delivery of team-based care in assigned clinic(s).
• Utilizes registries, electronic reports, and review of provider schedules to proactively assess and coordinate preventive screening, care coordination, and communication, documentation of measures and interventions via EHR. Assure that care is patient-centered.
• Uses clinical evidenced-based care guidelines to monitor patient health status and need for services by coordinating high-risk patient risk reduction, hospital and ER utilization, and improvement of patient outcomes.
• Uses IRIS and Idaho health Data Exchange to track immunization status and recall for immunizations.
• Collaborates with team members for appropriate tracking, follow-up of referrals and scheduling.
• Follows up with patients as requested by provider.
• Assists in education, assistance, support for patients and families, and care coordination with outside providers and community resources.
• Assess patients’ readiness to change, monitor compliance with plan of care, and problem-solve barriers related to the health care system, financial, and psychosocial barriers.
• Utilizes behavioral strategies to assist patients in adopting health behaviors, improving self-care and managing chronic disease.
• Assists Outreach and Enrollment staff with patient’s eligibility requirements for Medicaid, SSI, etc. and with coordination of enrollment with service agencies.
• Makes reminder calls for patient visits, to include but not limited to the guidelines set forth by FHS for PCMH and MU.
• Reviews Medicare, Medicaid, & other Payer reports and coordinates care with patients accordingly. Notifies schedulers of Medicare annual wellness visits needed.
• Collects, manages and reviews data and develops reports incorporated into the Quality Improvement Programs.
• Participates in FHS meetings and committees as assigned.
• Performs other duties as assigned.

Requirements

• RN, LPN, CMA or LSW licensure required.
• Prefer 2 years of experience in the fields of health, public health, or social service; an emphasis on community and population health and care coordination is desirable.
• Fluency in written and spoken English.
• Bilingual English/Spanish preferred.

Nice-to-haves

• Excellent organizational skills and strong written and verbal communication skills.
• Strong computer skills, particularly in Microsoft Office. EHR experience preferred.
• Ability to build and maintain effective partnerships internally and externally with an awareness of community resources.
• Ability to work with patient/client groups and/or experience in membership organizations.
• Ability to work with minimal supervision and maximum accountability to problem-solve and work independently and collaboratively as a member of a team.
• A professional demeanor, pleasant manner in telephone and personal contacts.
• Analytical skills with the ability to manage and prioritize multiple tasks.

Benefits

• $18.50 - $32.00 DOE.
• Employee's can receive up to $520 on the quarterly bonus.