Care Manager - RN, CMA, LPN or LSW

About the Role

The Care Manager is a key member of the medical home team, using registries and evidence-based guidelines to drive the proactive care process for clinic patients. This role facilitates communication, coordinates services, addresses barriers, and tracks the health of the patient population assigned to a provider panel in accordance with the goals and mission of Family Health Services.

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.
• Ensures care is patient-centered.
• Uses clinical evidence-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, support, and care coordination for patients and families with outside providers and community resources.
• Assesses patients’ readiness to change, monitors compliance with plan of care, and problem-solves 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 eligibility requirements for Medicaid, SSI, etc., and coordinates enrollment with service agencies.
• Makes reminder calls for patient visits, including those set forth by FHS for PCMH and MU.
• Reviews Medicare, Medicaid, and 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.
• Adheres to safety culture, completing all training requirements and reporting hazards or unsafe conditions.
• Ensures compliance with Medicare, state, and federal regulations, including accurate documentation and billing practices.
• Participates in Patient Centered Medical Home (PCMH) initiatives as an active team member.

Requirements

• RN, LPN, CMA, or LSW licensure required.
• Prefer 2 years of experience in health, public health, or social services, with an emphasis on community and population health and care coordination.
• Fluency in written and spoken English.
• Bilingual English/Spanish required.

Skills

• 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 awareness of community resources.
• Ability to work with patient/client groups or experience in membership organizations.
• Ability to work with minimal supervision, problem-solve, and work independently and collaboratively as a team member.
• Professional demeanor and pleasant manner in telephone and personal contacts.
• Analytical skills with the ability to manage and prioritize multiple tasks.

Pay

$19.00 - $32.25 per hour, dependent on experience. Employees can receive up to $520 in quarterly bonuses.

Working Conditions

Work is normally performed in a typical interior/office work environment. No or very limited physical effort required. No or very limited exposure to physical risk.