Description SUMMARY:

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. Requirements

MINIMUM QUALIFICATIONS

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 required. $19.00 - $32.25 DOE. Employee's can receive up to $520 on the quarterly bonus.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED

1. Excellent organizational skills and strong written and verbal communication skills. 2. Strong computer skills, particularly in Microsoft Office. EHR experience preferred. 3. Ability to build and maintain effective partnerships internally and externally with an awareness of community resources. 4. Ability to work with patient/client groups and/or experience in membership organizations. 5. Ability to work with minimal supervision and maximum accountability to problem-solve and work independently and collaboratively as a member of a team. 6. A professional demeanor, pleasant manner in telephone and personal contacts. 7. Analytical skills with the ability to manage and prioritize multiple tasks.

DUTIES AND RESPONSIBILITIES

1. Participates in the delivery of team-based care in assigned clinic(s). 2. 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. 3. 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. 4. Uses IRIS and Idaho health Data Exchange to track immunization status and recall for immunizations. 5. Collaborates with team members for appropriate tracking, follow-up of referrals and scheduling. 6. Follows up with patients as requested by provider. 7. Assists in education, assistance, support for patients and families, and care coordination with outside providers and community resources. 8. 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. 9. Utilizes behavioral strategies to assist patients in adopting health behaviors, improving self-care and managing chronic disease. 10. Assists Outreach and Enrollment staff with patient's eligibility requirements for Medicaid, SSI, etc. and with coordination of enrollment with service agencies. 11. Makes reminder calls for patient visits, to include but not limited to the guidelines set forth by FHS for PCMH and MU. 12. Reviews Medicare, Medicaid, & other Payer reports and coordinates care with patients accordingly. Notifies schedulers of Medicare annual wellness visits needed. 13. Collects, manages and reviews data and develops reports incorporated into the Quality Improvement Programs. 14. Participates in FHS meetings and committees as assigned. 15. Performs other duties as assigned.

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. 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