Healthcare for the Homeless Care Manager

Working title: Healthcare for the Homeless Care Manager

Classification title: Care Manager

Division: Main Clinic, HCH

Program: Care Management

Reports to: Community Partnerships Program Manager

FLSA status: Non-Exempt; Full-time

Schedule: Monday-Friday; 8am-5pm

Wage Range: $20.48-$26.06 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 the communities we serve.

Foremost, we are committed to the values of Justice, Equity, Diversity and Inclusion (JEDI) by cultivating an environment that protects and acknowledges the unique identities within our diverse community.

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 provides comprehensive care management services to assigned high-risk patients who are at risk for poor health outcomes and those living without housing. The Care Manager will act as a member of the Patient Care Team for coordination of care, identify barriers to care, assess their individual needs and providing education on understanding 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 patient centered care plan objectives and connecting patients to resources. This position will be housed at the Healthcare for the Homeless locations 2424 1st Ave North, and St. Vincent de Paul.

Essential Functions/Major Duties and Responsibilities:

A. Care Manager Duties 80%

• Meeting patients where they are, includes street medicine and community outreach for the unhoused population.

• Provides Care Management services to all patients and specifically patients identified as high risk. Assesses 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 considering the patients’ medical, nutritional, mental health, psychosocial, substance abuse history, financial, education/employment other possible community resource needs in accordance with Patient Centered Medical Home (PCMH) Standards and Guidelines.

• Work with each patient to identify and develop individualized personal long term and short-term goals such as improving therapeutic outcomes and development towards independence.

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

• Maintains active caseload and conducts multiple forms of outreach to monitor patient symptoms, provide patient education and work on patient goals, which is documented in the electronic medical record.

• Provides crisis assistance to patients while in clinic by accessing local programs, Community service providers and agencies to meet patient’s needs.

• 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, how to appropriately use health coverage option to reduce disparity for all persons.

• Coordinate communication between patients, family members, medical staff, administrative staff, or regulatory agencies to ensure continuity of care is accomplished across the spectrum of care.

• Identify and refer clients to appropriate community resources and programs to ensure a full array of services are available to all patients.

• 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.

• Respond to patient’s questions and comments in a courteous and timely manner.

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

• 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 insurances.

• Provides guidance for patients that need help navigating the healthcare system and who may not qualify for health insurance or financial assistance programs.

• 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.

B. Health Care for the Homeless 15%

• Significant knowledge of community resources, services and programs available to assist clients.
• Uses community platforms to identify patient population and stay current in community
• Establish and maintain effective working relationships with other agency, organization and tribal entity representatives.
• Participates in various community events by representing RiverStone Health Clinic and provide accurate information regarding Clinic services available.
• Acts as an advocate for the patient within the patient care team and other community support services and organizations.
• Participate in and attend meetings, conferences, workshops and trainings to remain current on the principles, practices and new developments in healthcare.
• Works collaboratively with other Healthcare for the Homeless team members to conduct outreach in the community, focusing on those who are experiencing homelessness.
• Initiates contact with isplays appropriate, professional, healthy boundaries and exercises mature judgment and understanding of safety concerns.
• abpersons experiencing homelessness, provides information about services and identifies barriers to care as well as opportunities to overcome barriers.
• Provides education, guidance and follow-up to persons experiencing homelessness and makes appropriate referrals to other services or agencies in coordination with others on the HealthCare for the Homeless care team.
• Provide Support at Satellite Clinics for access to resources and planning. Including enrolling patients for services, answering phone, greeting patients, and aiding patients in all requirements to become patients at Riverstone Health.
• Other duties as assigned

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 RiverStone’s mission and goals.

Education and Experience:

Minimum Qualifications

• High School diploma or equivalent

• Experience in a social work or medical setting

• Any combination of experience and training which provide the equivalent scope of knowledge, skills, and abilities necessary to perform the work.

• Must have vehicle in good working condition and demonstrate proof of insurance coverage

Preferred Qualifications:

• Experience working with underserved population

• Experience working in a customer service environment

Required Certificates, Licenses, Registrations:

• Valid Montana driver’s license

• Certified Application Counselor (may complete after hire)

• Chronic Care Certification (may complete after hire)

Knowledge, Skills, and Abilities:

• Computer literacy, in Microsoft Office Suite.

• 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

• Traveling required between outreach and clinic sites

• 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.

Education

• High School or better

Behaviors

• Functional Expert: Considered a thought leader on a subject
• Team Player: Works well as a member of a group
• Dedicated: Devoted to a task or purpose with loyalty or integrity

Motivations

• Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization
• Self-Starter: Inspired to perform without outside help
• Work-Life Balance: Inspired to perform well by having ample time to pursue work and interests outside of work