About On Belay Health Solutions

On Belay Health Solutions is a Massachusetts-based physician-led managed services organization (MSO) devoted to supporting independent primary care physicians. On Belay provides enhanced Medicare value-based contracts that empower physicians with the resources necessary to invest in innovative care models and population health management tools. This allows physicians to practice medicine and positively impact the health of their communities in the way they have always dreamed. 

About the role

On Belay is seeking a motivated, passionate Care Manager to assist our provider partners’ Medicare patients. The goal of the care manager is to assist identified patients with developing their health goals and creating a plan to manage real life issues that keep them from achieving those goals. The Care Manager will collaborate with other team members to conduct needs assessments and identify and respond to barriers to their health and wellness. 

Benefits include a generous holiday and paid time off policy. Health and dental reimbursement plans. Applicants must be based in the Starkville, MS area and be willing to perform duties onsite at least two days per week with our physician practice partners within one hour driving distance from Starkville. On Belay is open to flexible work arrangements, including remote work on offsite days. 

We look forward to meeting interested applicants and mutually assessing fit in joining On Belay on our important mission to transform healthcare! 

What you'll do

• Develop trusting relationship with patients by providing support and advocacy to help achieve health goals 
• Coordinate transitions of patients to/from acute inpatient, skilled nursing and other settings. Assist patients in accessing community resources (e.g., food stamps, meals on wheels, subsidized housing, free legal services, Medicaid/Medicare applications, support groups etc.)
• Meet with patients in patient-centered and patient-preferred locations (e.g., center, facility, home, community setting). 
• Manage low-risk referrals defined by care management program (Medical Social Work) & collaborate with social worker on action plan 
• Engage with high-risk individuals (e.g., completed specialty appointments, adherence to post-discharge visits); may include accompanying patients to appointments 
• Assist completion of applications to access eligible benefits
• Perform wellness checks in homes, participate in remote monitoring program education on individuals with specific health conditions
• Provide health screenings, referrals and information
• Deliver health education presentations
• Facilitate communication between all identified parties by the patient involved in care (e.g., family members, care givers, medical providers, community-based organizations). 
• Document interactions with patients in medical record 
• Coach / train early career Care Managers, potentially in a management role
• Any other related duties assigned at manager’s discretion

Qualifications

• Current unrestricted Mississippi RN license required  
• Previous work experience in a primary care setting, care management role, and/or a home care manager 
• Must be a self-directed individual able to work diligently without direction, think critically and prioritize.  
• Basic computer skills including working knowledge of Microsoft Office products 
• Demonstrated experience with Electronic Medical Records (EMR) systems, with a strong preference for proficiency in Cerner and Allscripts 
• CCM (Certified Case Manager) or ACM (Accredited Case Manager), preferred
• Bachelor's degree or higher , preferred
• Experience working with aging population and/or community health, preferred
• Knowledge of health plans, Medicare, Medicaid, preferred

Benefits 

• Hybrid work environment 
• Monday - Friday Scheduling 
• Generous holiday and paid time off policy. 
• 401k 
• Health and Dental coverage plans 
• Flexible Work Arrangements
  
  We offer a competitive base salary ranging from $90,000 to $95,000 annually, depending on experience.

We are an equal opportunity employer. Employment selection and related decisions are made without regard to age, race, color, national origin, religion, sex, disability, sexual orientation, gender identification, or being a qualified disabled veteran or qualified veteran of the Vietnam era or any other category protected by Federal or State law.