||Purpose of Position: Under the supervision of the Case Management Supervisor, the incumbent is to provide case management services to the highest risk patient population and assist in oversight of Care Coordinators. This position will work to enhance communication, coordinate needed services, address barriers, and track the health of the patient population assigned in accordance with the goals and mission of Valley Family Health Care. Responsibilities will facilitate and support high quality, collaborative patient care delivery and, minimize fragmentation which generally results in more cost-efficient care and healthier patient outcomes.
1. Must hold RN license in state of primary workplace and be licensed in the other state (Idaho/Oregon) within 90 days of hire date. Oregon and Idaho licensures must be maintained at all times.
2. Must hold and maintain current AHA BLS card (healthcare provider), AHA ACLS and PALS certification or obtain ACLS and PALS within 6 months of hire.
3. Minimum two years’ experience working in the field of health care, public health, or social services, with an understanding of best practices in chronic disease case management and principles of population health.
4. Experience and expertise in case management processes and mentoring and coaching other staff members is preferred.
5. Must be accurate, exacting, orderly and methodical in work detail.
6. Willing to work for the successful accomplishment of VFHC goals and objectives.
7. Speech must be clear, distinct and convincing, with fluency in written and spoken English. Spanish fluency preferred.
8. Excellent organizational skills and strong written and verbal communication skills.
9. Strong computer and internet skills, particularly in Microsoft Office – Word, Excel, Outlook, PowerPoint, OneNote.
10. Able to build and maintain effective partnerships internally and externally with an awareness of community resources.
11. Able to work with minimal supervision and maximum accountability to problem-solve, as well as to work collaboratively as a member of a team.
12. Possess neat and professional demeanor with pleasant manner in telephone and personal contacts.
13. Analytical skills with the ability to manage and prioritize multiple tasks.
14. Fluency in written and spoken English. Spanish fluency desirable.
15. Hold and maintain valid Driver’s License and clean driving record.
1. Provide Chronic Care Management (CCM) to highest risk population.
2. Support care of patients with substance abuse and alcohol abuse disorders on Controlled Substance Agreements.
3. May participate in and manage Transitional Care Management (TCM).
4. Utilize registries, electronic reports and review of provider schedules to determine patient case management needs and coordinate care.
5. Proactively assist patients to navigate the health care system, helping coordinate with outside providers and community resources.
6. Track and follow-up of referrals, in conjunction with the central referral desk staff.
7. Notify Valley Family Patient Service Representative of patient need for visit based on recall and evidence-based care guidelines.
8. Follow up with patients as requested by provider. Work with patient to fulfill the provider driven care plan, while ensuring care is patient centered.
9. Assist Outreach and Enrollment staff with patient’s eligibility requirements for Medicaid, SSI, etc. and with coordination of enrollment with service agencies.
10. Review Medicare, Medicaid, & other Payer GAP reports and coordinate closing identified care gaps with patients accordingly.
11. Utilize behavioral strategies to assist patients in adopting healthy behaviors, improve self-care and manage chronic disease.
12. Monitor compliance with plan of care, and problem-solve barriers related to the health care system, including financial, and psychosocial barriers.
13. Promote clear communication among the patient care team by ensuring awareness regarding patient care plan and needs.
14. Promote safe and appropriate patient medication management through medication reconciliation and education.
15. Support patient’s self-management of chronic disease and readiness to make needed behavior modifications, identified through patient health and disease management interviewing and coaching in collaboration with available resources.
16. Participate in data collection and health outcomes reporting related to patient centered care and VFHC Quality Improvement Programs and initiatives
17. Assist with supervision of Care Coordinators, including reviewing charts and care plans, panel size, and performing needed case management duties outside the Care Coordinator scope of practice including medication reconciliation.
18. Participate in VFHC meetings and committees as assigned.
19. Assist with meeting quality measures by completing tasks related to VFHC initiatives.
20. Perform other duties as assigned.
1. Must be able to lift 25 lbs.
2. Continuous sitting, standing, walking.
3. Correctable vision and hearing.
4. The ability to communicate information and ideas so others will understand. Must be able to exchange accurate information in these situations.
5. The ideal candidate must be able to complete all physical requirements of the job with or without a reasonable accommodation.
6. Need to have Covid vaccination or be willing to get vaccinated. Accommodations considered for Medical and Religious reasons.