Post Partum Support Specialist

Essential functions/Major duties and responsibilities

• A. Care Manager Duties 40%
• Provides Care Management to clients by identifying individuals who are likely to benefit from effective care management, using criteria applied to the client population, or by client referral by any member of the RiverStone Health team or outside referral agencies
• Performs client assessment and develops individual care plans. Care Plan documentation includes evaluating the client’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 and/or in-person home visits to monitor client symptoms, provide client education and work on client goals.
• Work with each client to identify individualized personal healthcare goals such as improving therapeutic outcomes. Works to set and document attainable long and short term goals for individual progress.
• Ensure that client 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 clients , family members, medical staff, administrative staff, or regulatory agencies.
• Respond to client’s questions and comments in a courteous and timely manner.
• Explain policies, procedures, or services to improve clients’ medical literacy.
• Identify and refer clients to appropriate community resources and programs.
• Follows up with outside care providers, agencies and community service providers to ensure that the client receives appropriate assistance.
• Track client 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 client within the client’s care team and other community support services and organizations.
• Provides support to and utilizes motivational interviewing techniques to guide clients in following treatment plans and achieving life goals.
• Maintains proficiency in computer skills to include Outlook, Word, and Excel programs. Enter client data into a computer database and/or spreadsheet
• Accurately and appropriately document client information in a timely manner and in accordance with RiverStone Health Public Health Services policies and procedures.
• Use logical and creative thought processes to develop solutions according to written specifications and/or oral instructions.
• Provide support to Satellite Clinics as requested

• B. Program Specific Duties 55%
• Conduct postpartum visits in a location of the mother’s choosing using a relationship-based and strengths-focused approach.
• Build trusting relationships that support maternal well-being, parenting confidence, and infant development.
• Provide education related to postpartum adjustment, maternal mental health, infant care, infant feeding, safe sleep, bonding, and community supports.
• Administer Edinburgh Postnatal Depression Scale (EPDS) and Ages & Stages Questionnaires (ASQ) or other approved screenings and discuss results with families.
• Maintain an active caseload and schedule regular follow-up visits or check-ins.
• Identify family-driven goals and provide bridge-to-resource navigation, including referrals to healthcare, community supports, behavioral health, and early childhood services.
• Utilize motivational interviewing and trauma-informed approaches.
• Protect confidentiality and adhere to HIPAA requirements.
• Support prevention-focused education aligned with Health Promotion priorities.
• Identify gaps in area services or resources to inform future initiatives supporting families with young children in Yellowstone County.
• Engage in community relationship building and organizing activities that strengthen the local postpartum support network to help normalize postpartum support and reduce stigma around seeking help during early parenthood.
• Attend community meetings, events, or classes to support warm handoffs among clients and their families.
• Conduct community outreach regarding the program, to include presentations, tabling events, information distribution, and more.
• Actively participate in Pathways Hub pilot program, including engagement in project team meetings and feedback sessions.
• Contribute to reports and data collection a required by associated funders, evaluation plans, and Pathways Hub.

• 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 community-based services 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, health promotion, public health or closely related field
• Training or certification as a community health worker (CHW)
• Training or certification in lactation support (e.g. Certified Lactation Counselor (CLC), Certified Lactation Specialist (CLS), Certified Lactation Educator (CLE), La Leche League Leader)
• Experience in community organizing, peer support, family support, early childhood programs, or maternal health programs

Required certificates, licenses, registrations

• Valid Montana driver’s license

Knowledge, skills, and abilities

• Knowledge and understanding of protected sensitive patient health information (HIPAA) and confidentiality
• 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 clients, maintain awareness of social and/or medical issues, and a willingness to work with underserved, under- or un-insured, and low-income clients, 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.
• Passion for public health, community health, maternal health and/or related focus areas.
• Thorough knowledge of modern office procedures, practices, and equipment.

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

• Position typically works Monday –
• Friday, 8:00 a.m. to 5:00 p.m. with occasional evening and weekend hours required
• Frequent standing, bending, sitting, lifting required
• Frequent customer interaction via telephone and in person in office and community
• Frequent travel throughout Yellowstone County to include clinical, community, and client home settings as appropriate
• 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 Early Interventions Services Program Coordinator as needed.
• Use independent judgement when in the field, with readily available access to someone for questions as needed.

Communications & networking

• Daily written and verbal communication with clients and their families, co-workers and community partners.
• Frequent presentations and outreach with internal and community partners.
• Maintain HIPPA compliant records and communication.

Budget & resource management: No budgetary authority

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