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Care Manager- AWARE

3 months ago

Billings, United States RiverStone Health Full time
Working title: Care Manager

Classification title: Patient Representatives

Division: School-Based Health Clinics

Program: Care Management- Project AWARE

Reports to: SBHC Program Manager

FLSA status: Non-Exempt; Full-time

Schedule: Monday-Friday; 8am-5pm

Wage Range: $20.48 to $26.06 hourly; depending in 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 of 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 will provide care management to high-risk patients who are at risk for poor health outcomes and provide Care Management for those patients. The Care Manager will act as a member of the Patient Care Team to identify barriers to care and to understand 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 care plan objectives.

*This position is a 5 year grant funded position in partnership with the Billings Public School District 2 (grant ends 9/30/25)*

Essential Functions/Major Duties and Responsibilities:

A. Care Manager Duties30%

  • Provides Care Management to patients by identifying high risk 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. Care Plan documentation includes evaluating the patient's medical, psychological, social, financial and educational/employment history, any history of substance abuse and any services currently being received by the patent.
  • Maintains active caseload and conducts multiple follow-up calls to monitor patient symptoms, provide patient education and work on patient goals.
  • Work with each patient to identify individualized clinical and personal healthcare goals such as improving therapeutic outcomes. Works to set and document attainable long and short term goals for individual progress.
  • 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 and how to appropriately use health coverage options.
  • Coordinate communication between patients, family members, medical staff, administrative staff, or regulatory agencies.
  • 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.
  • Identify and refer clients to appropriate community resources and programs.
  • 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.
  • 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, and other insurances.
  • Significant knowledge of community resources, services and programs available to assist clients.
  • Acts as an advocate for the patient within the patient care team and other community support services and organizations.
  • Provides support to and utilizes motivational interviewing techniques to guide patients in following treatment plans and achieving life goals.
  • 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.
  • Accurately and appropriately document patient information in a timely manner and in accordance with RiverStone Health Clinic policies and procedures.
  • Use logical and creative thought processes to develop solutions according to written specifications and/or oral instructions.
B. AWARE Care Manager Duties65%
  • Works as a member of the AWARE (Advancing Wellness and Resilience in Education) team to deliver comprehensive care in collaboration with the school-based mental health programs staffed by behavioral health specialists and the school wellness teams
  • Conduct outreach and engagement with school-aged youth and their families to increase awareness and identification of mental health issues and to promote positive mental health.
  • Connect families, schools and communities to increase engagement and involvement in planning and implementing school and community programs for school-aged youth.
  • Provide coordinated referral, services and follow-up to school aged youth and their families for evidenced-based school and community-based mental health practices and services.
  • Develop and implement meaningful ways to engage students and their families by involving them in the plan of care, by providing support to and motivating student and family in following treatment plan and achieving goals.
  • Meets with the student and family, along with the RiverStone Health Licensed Behavioral Health provider to develop an individualized treatment plan for the student.
  • Participates in planning, implementing, coordinating, monitoring and evaluating the behavioral treatment options and strategies for students and families.
  • Provides care management services by serving as a liaison between primary care providers, specialty providers and behavioral health providers to coordinate medical and behavioral health services and ensure communication.
  • Provides on-going emotional support and acts as an advocate of the student within the student care team and other community support services and organizations.
  • Participates in regularly scheduled caseload review with the AWARE team (such as medical provider, behavioral health) and communicates recommendations and student status with meeting established health goals).
  • Provide Care Management to school-aged youth who may have behavioral health issues (including serious emotional disturbance [SMI] and connect these youth and families to needed services.
  • Works with the AWARE team to provide data required for the grant reporting elements of the AWARE grant
  • Participates in any of the AWARE summer programming for youth developed by the licensed mental health provider
  • Collect, prepare and enter data accurately into the electronic healthrecord in a timely manner
  • Proper documentation and verification of patient's insurance information, answering calls, scanning patient documents and preparing correspondence
  • Provide patient services, which may include greeting, registration, making appointments, rescheduling, follow-up, outreach and medical record requests
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:
  • Bachelor's Degree in social work, sociology, human services, psychology, or closely related field
  • One or more years of medical office and/or electronic health record experience
  • Experience In care management of youth and their families and
  • Experience in a school setting
Required Certificates, Licenses, Registrations:
  • Valid Montana driver's license (required to travel between RiverStone Health AWARE school locations and the main campus)
Knowledge, Skills, and Abilities:
  • Knowledge and understanding of protected sensitive patient health information (HIPAA) and confidentiality
  • Knowledge and understanding of FERPA (Family Educational Rights and Privacy Act)
  • 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
  • Frequent travel between RiverStone Health, the Billings Public Schools K-8, and Lincoln Center
  • May travel between outreach clinic sites within the Billings community
  • 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 SBHC Program Manager and/or Care Management Team (NOTE- this person has minimal contact with the CM team- but the team is the peer group for CM specific questions and are encouraged to attend the care manager team meetings if appropriate)
Communications & Networking:
  • Daily written and verbal communication with patients and their families, co-workers and community partners.
  • Maintain HIPPA compliant records and communication.
  • Maintain FERPA communications.

Budget & Resource Management:

No budgetary authority