Care Manager

Description

SUMMARY:

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. 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.

$21.50 - $24.50: DOE for LPN/LSW

$28.00 - $32.00: DOE for RN

Employee's can also receive up to $520 on the quarterly bonus.

Minimum Qualifications

Valid RN, LPN or LSW licensure for the state of Idaho is required, also CMA, RMA and CHW. 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 and Spanish preferred. Must have a valid driver’s license.

Knowledge, Skills, And Abilities Required

• Excellent communication and interpersonal skills to effectively engage with the patients.
• 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.
• Proficient in data collection and basic computer skills for documentation and reporting purposes.
• Understanding of health education principles and the ability to effectively communicate health-related information.
  
  

Description Of Duties

• Participate in the delivery of team-based care in assigned clinic(s).
• Utilize registries, electronic reports, and review of provider schedules to proactively assess and coordinate preventive screening, care coordination, and communication, and documentation of measures and interventions via EHR. Assure that care is patient centered.
• Use 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.
• Use IRIS and Idaho health Data Exchange to track immunization status and recall for immunizations.
• Collaborate with team members for appropriate tracking, follow-up of referrals, and scheduling.
• Follow up with patients as requested by provider.
• Assist in education, assistance, and support for patients and families, and care coordination with outside providers and community resources.
• Assess patients’ readiness to change, monitor compliance with care plans, and problem-solve barriers related to the health care system, and financial and psychosocial barriers.
• Utilize behavioral strategies to assist patients in adopting healthy behaviors, improving self-care, and managing chronic disease.
• Assist outreach and enrollment staff with patients’ eligibility requirements for Medicaid, SSI, etc., and with coordination of enrollment with service agencies.
• Make reminder calls for patient visits.
• Conduct individual health education sessions delivering information on preventive care, disease management nutrition, exercise, and other health-related topics.
• Assist patients in accessing health related services.
• Serve as an advocate for the patients, helping them navigate the healthcare system, addressing barriers to care, and promoting policies that improve their health.
• Participate in ongoing training, learning sessions, conference calls, webinars and other professional development opportunities as allowed.
• Document and maintain records of encounters with individuals.
• Meet regularly with the supervisor to review activities and identify problems and priorities.
• Review Medicare, Medicaid, & other payer reports and coordinate care with patients accordingly. Notify schedulers of Medicare annual wellness visits needed.
• Collect, manage, and review data and develop reports incorporated into the Quality Improvement Programs.
• Participate in FHS meetings and committees as assigned.
• Perform other duties as assigned.
  
  

Requirements

OTHER RESPONSIBILITIES:

Safety

Family Health Services enforces a safety culture whereby all employees have the responsibility for continuously developing and maintaining a safe working environment. Each employee is responsible for completing all training requirements, participating in emergency response tasks as requested, and serving on safety committees and teams as requested. In addition, employees must accept the responsibility for maintaining the safety of themselves and others by adhering to all written and verbal instructions, promptly reporting and/or correcting all hazards or unsafe conditions, and providing feedback to supervisors and management on all safety issues.

Compliance (medicare)

Family Health Services is committed to the very highest standards of ethics and integrity. It is our policy to properly determine the accuracy of reporting and billing our services in accordance with the rules, laws and regulations of FHS, the state government, and the federal government. FHS employees will do their part to ensure accurate documenting and billing practices, participate in compliance trainings and will identify and report any concerns or activities that may violate these standards.

Each employee will be trained on the FHS Medicare Compliance Plan and the Standards of Conduct and asked to sign a Conflict-of-Interest Statement at hire and annually thereafter. A copy of the Medicare Compliance Plan and the FHS Standards of Conduct are available on the FHS home page under the Compliance tab.

Patient Centered Medical Home (pcmh)

Family Health Services is committed to providing our patients with the highest standards of care by becoming recognized as patient centered medical home. FHS staff is expected to participate in this process by being an active and willing PCMH team member. Specific duties and expectations may vary and will be identified by position and site.

Procedure Compliance

Employee must read and understand the general and specific operational, safety, and environmental requirements of all plans, procedures, and policies pertaining to this job.

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.

Acknowledgment

I have received, read, and understand my job description. My signature below attests to the fact that I can perform the essential functions of the job with or without reasonable accommodation.