Medicare Wellness, Clinical Liaison & Transitional Care Manager

  • Full Time
  • Personal Trainer
  • Anywhere

Southwest Montana Community Health Center

Medicare Wellness & Clinical Liaison – Transitional Care Manager

Full-time, benefits-eligible

FLSA non-exempt

Wage DOE

SWMTCHC Core Competencies, Mission, and Vision

Integrity and Trust

Is widely trusted; is seen as a direct and truthful individual; can present the unvarnished truth in an appropriate and helpful manner; keeps confidences; admits mistakes; doesn’t misrepresent themselves for personal gain.


Maintains confidentiality of others’ personal information; can be trusted to represent the SWMTCHC outside the organization; meets and complies with all medical, regulatory, and licensing standards; takes ownership of their own actions and is accountable for their own mistakes; follows through on what they say they will do.

Mission and Vision Integration

Adheres to the Mission and Vision of the SWMTCHC during both good and bad times; is dedicated to meeting the expectations and requirements of the SWMTCHC mission and vision; acts in line with the values of the mission; practices what they preach.


To inspire hope and empower wellness by providing access to comprehensive healthcare


A stronger Montana through community and wellness


Articulates and sincerely demonstrates the mission consistently through examples such as: treating all people (patients/staff/other agencies, etc.) equally; non-judgmental; listens to others without making assumptions, uses eye contact and acknowledges others; makes decisions that are focused on the patient/staff.

Team Relations

Understands and supports the team approach; s seen as team player and is cooperative; easily gains the trust and support of peers; encourages collaboration; can be candid with peers; fosters open dialogue; creates a feeling of belonging to the team.


Effectively able to communicate (can give and receive both positive and constructive feedback) with peer group and other staff to get the message across; knows appropriate team members to consult relative to the issue or situation; willingly shares knowledge and information with appropriate team members; actively seeks opportunities to help the team.

Position Summary

The transitional care manager is a clinical liaison position between members of the community who seek services at the CHC and have provisional needs. The transitional care manager will provide these services by working and collaborating with the entire healthcare team at the SWMTCHC. This team includes providers, pharmacy staff, nursing staff, medical assistants, care management, behavioral health, team assistants, all clerical, financial, and medical records staff, and all supervisors. The transitional care manager will perform patient care duties in collaboration with the health care team (the medical provider is the team leader). The transitional care nurse will focus on building and maintaining relationships with clients and families, discharge planners, social workers, and other facility personnel. In this role you will utilize your nursing abilities to assess patients’ medical and social needs to identify appropriate home care services. Working with the SWMTCHC staff you will lead the intake/discharge processes for clients that will be leaving the hospital, entering a facility for transitional housing or long-term care, or returning home.

In addition to providing transitional care services, this position involves coordinating and providing Medicare annual wellness exams for clinic eligible clinic patients.

This position requires an individual who is able to develop and build strong, lasting relationships with referral sources, clients, and families. Excellent planning, organization and presentation skills are critical.

Position Requirements

  • Must hold valid MT license for LPN or RN
  • Minimum one-year experience preferred in an acute, long term or ambulatory care environment
  • Demonstrated ability to problem solve
  • As defined by Nursing Competencies has the following demonstrated abilities:
  • Ability to work both independently and interdependently
  • Excellent customer service skills
  • Demonstrated effective communication skills
  • Flexibility in working in a team setting
  • Critical Thinking and problem-solving skills

Essential Functions, Roles, and Responsibilities (not exhaustive)

Patient Identification/Intake

  • Daily discharge planning meetings with hospital
  • Use EMR to identify any clinic referrals from SWMTCHC providers
  • Work in conjunction with SWMTCHC providers and staff to provide efficient and high-quality discharge planning for patients.
  • Assessment/coordination for patients needing follow up appointments at SWMTCHC.
  • Transitional planning/liaison for patients discharging from the hospital to transitional care/long term care.
  • Transitional planning/liaison for patients discharging from the transitional care to home setting.
  • Review allergies
  • Medication reconciliation
  • Review and discuss patient’s tobacco, alcohol, and illicit drug use
  • Review and document disease collaborative items as necessary
  • Perform coordination for standing order or pre-ordered labs, weight checks, and patient education as appropriate to each individual patient
  • Assist patient in setting self-management goals using intake form as guide. Document goals in Epic
  • Complete, document, and review patient history in EMR
  • Perform Social Determinants of Health questionnaire and provide patients with families with adequate community resources
  • Perform Medicare Wellness visits under direction of the medical provider and per protocol

Learning Responsibilities/Taking Direction

  • Willing to learn team responsibilities as needed – electronic medical record and clinic flow change over time and with performance improvement and developments in technology
  • Takes personal responsibility to understand new procedures by following direction of trainer and completing self-learning packets as available
  • Takes responsibility to request and attend appropriate CE offerings annually

Follow Standard Procedure for Order Entry and Documenting in EMR:

  • Immunizations are ordered in EMR (future), historical immunizations are documented in EMR
  • Maintain medication list, new and updates in EMR
  • Maintain patient history in EMR
  • Provider orders/instruction in progress note
  • Lab results obtained, know abstraction/scanning procedures
  • Pertinent patient information gained face to face, by phone or fax
  • Referrals to outside agencies for testing or specialist care.
  • Maintain tracking of referrals or collaborate with team members to ensure referral tracking completed

Infection Control—Follows Standard Procedures

  • Demonstrates proper hand washing 100% of the time
  • Keeps work areas clean—all exam rooms, treatment room, lab room, nurse visit room, and desk area
  • Empties sharps containers regularly—no container is ever in a room with contents above ‘the line’

Miscellaneous Duties

  • Accepts all phone calls which communications are involving hospital, long term care facilities, transitional facilities, home health, hospice, etc.
  • Assists in the maintaining all incoming/outgoing faxes involving hospital, long term care facilities, transitional facilities, home health, hospice
  • Under the direction of the provider is the liaison with SWMTCHC staff, facilities, and patient family members
  • Obtains physician order to oversee plan of care via telephone or fax
  • Responsible for establishing, growing, and maintaining relationships with facility-based referral sources in accordance with SWMTCHC policies and procedures, by both communicating with existing referral sources and identifying new opportunities
  • Communicates with providers and staff several times daily
  • Asks for help from other staff as needed
  • Uses courteous phone skills at all times
  • Completes unusual occurrence/incident reports per standard procedure
  • Arranges for coverage for lunch or meeting attendance—keeps other nurses informed of whereabouts during work time
  • Request time off in a timely manner in accordance with SWMTCHC policy

Continuum of Care Responsibilities

  • Review medical tests received by clinic
  • Checks in tests with date stamp and signature
  • Brings urgent/emergent test results to provider immediately
  • Notify patient of lab results and/or treatment plan/changes as instructed by provider—by phone or letter and documents in medical record
  • Return patient phone calls during the shift they are received (within one business day of receipt)
  • Assist in electronic and paper medication refills, these should be complete within 3-5 business days of receipt
  • Answer patients’ questions or direct them to appropriate resource
  • Prioritize patient needs by gathering data and using that information to make an appropriate decision regarding care or referral of the patient
  • Assist with MyChart communication based on provider preference.
  • Keep medical provider focused on tasks: patient visit, electronic signing of encounters, signing off paper labs/test results, completing result notes for electronic lab results, hospital communications, nursing home follow up calls, meetings. Productivity goal: Medical team will see 20-24 patients in an 8 hour shift

Knowledge, Skills and Abilities

  • Competent in dealing with diverse populations
  • Knowledge of health record keeping and charting
  • Knowledge of OSHA Blood borne Pathogen Standards and adherence to safety standards
  • Ability to operate a computer and job-related software
  • Excellent oral and written communication skills
  • Ability to organize and prioritize tasks
  • Ability to work under pressure
  • Strong attention to detail and problem-solving skills
  • Ability to work independently and as a team member

Legal Concepts

  • Practices with the scope of education, training, and personal capabilities
  • Maintains confidentiality
  • Follows federal, state and local legal guidelines; follows license criteria when licensure applies
  • Maintains HIPAA & OSHA compliance
  • Maintains OSHA compliance
  • Reports any evidence of abuse or neglect to provider or appropriate official

Supervision: This position has no supervisory responsibilities

Immediate Supervisor: Nursing Supervisor, COO

Physical Demands/Working Conditions:

General office/clinic conditions are pleasant; good, clean working conditions where accident and hazards are negligible; requires short periods of moderate lifting, pushing or pulling objects up to twenty pounds. Clear diction and acute hearing are necessary for effective communication with the staff and public.

OSHA Classification I: Normal work routine involves potential for mucous membrane or skin contact with blood and/or body fluids; use of appropriate protective measures is required.

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change, or new ones may be assigned at any time with or without notice.

Southwest Montana Community Health Center is an Equal Opportunity Employer

Job Type: Full-time

Pay: $23.77 – $27.39 per hour


  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Disability insurance
  • Employee assistance program
  • Employee discount
  • Flexible spending account
  • Health insurance
  • Life insurance
  • Paid time off
  • Retirement plan
  • Vision insurance

Medical Specialty:

  • Primary Care


  • 8 hour shift
  • Monday to Friday


  • Epic: 1 year (Preferred)
  • acute, long-term, or ambulatory care: 1 year (Required)


  • LPN (Preferred)
  • RN (Required)

Company’s website:


Work Remotely:

  • No

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