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One Health Patient Resource Specialist in Miles City, Montana

POSITION SUMMARY : The Patient Resource Specialist (PRS) supports the resource needs of our community’s most vulnerable patients. This position helps patients navigate social systems and barriers to care through referrals and direct services such as care coordination, health education, transportation assistance, and assistance with obtaining food, shelter, and benefits. PRSs work with patients as part of the integrated care team and develop and maintain positive relationships with partners who provide support services.

COMPENSATION: $16.90-$18.91 hr/ DOE


AVAILABILITY: Monday to Friday

BENEFITS: We offer a competitive compensation package that includes paid time off, nine paid holidays, discounted health care for employees and their family members, as well as health, dental, & vision insurance, disability insurance, health savings account, and matching retirement plan for all employees working at least 20 hours/week.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions.

ABOUT ONE HEALTH: With multiple clinic sites across Montana and Wyoming, One Health provides medical, dental, pharmacy, behavioral health, and community and public health services to rural populations through an integrated approach to health care.

One Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Patient Resource Specialist (PRS) 1:

  • P articipates on care teams to promote and coordinate whole health services to meet patient and organizational goals and outcomes with a special emphasis on supporting the resource needs of our most vulnerable patients.

  • Serves as liaison within our Patient Centered Medical Home model, between patients, care teams, specialty services, and community resources around social drivers of health (SDOH) to help patients navigate health care barriers to care and social systems (Insurance enrollments, referrals for basic needs, transportation, etc.).

  • Completes SDOH screenings with patients to identify needs and documents these needs in the patient chart. Working with integrated care team, prepares a plan to set goals to overcome barriers and implement strategies to improve health goals.

  • Tracks patient goals and outcomes. Works in partnership with the care team, patient, and/or their caregiver, and/or family member to meet resource-oriented care goals and reduce barriers to care along their care journey, to include follow up and care management.

  • Completes Warm Hand Offs (WHO’s), working with patients while in the patient room, as requested by the care team members.

  • Uses professional methods to document referral outcomes and follow-up, charts appropriately when in the patient record using proper methods and workflow.

  • Practices proactive communication of patient outcomes to the referring care team for continuity of care.

  • Scrubs charts and prepares data to present patient needs to care team through huddle and care management meetings.

  • Maintains an appointment schedule in the electronic medical record and uses it to schedule encounters with patients in face-to -face, phone, telehealth, or community-based settings.

  • Performs targeted outreach to patients identified through risk stratification, service contracts, payers, or other means to schedule appointments for patients recommended by the care team, and to connect patients with services within the organization and community.

  • Supports the patient in successfully bridging gaps to care and to assist patients with barriers impacting no-shows to appointments.

  • Initiates and maintains contact and a presence with key community resource providers on a regular basis, to build positive relationships and build partnerships and educational and support services.

  • Updates partners on organizational services available, improves access for referred patients, and works together to best meet needs of shared clients.

  • Connects and refers patients with appropriate resources and services.

  • Assists patients in completing paperwork and making connections necessary to access resources. This includes, but is not limited to, completing coverage applications, gathering required documentation, and troubleshooting the enrollment process for uninsured children and adults to access subsidized, low-cost, and free health insurance programs including Medicaid and the Children’s Health Insurance Program (CHIP).

  • Manages confidential and sensitive information and data to comply with organizational policy and HIPAA guidelines. This may include patient information such as medical records, verification of employment and a release of patient records.

  • Ensures patient applications and access to Health Share Partnership (HSP) are completed and renewed as required.

  • Manages non-clinical referrals and internal assistance programs (i.e., gas, dental, Rx) and with partnering service providers.

  • Maintains proficiency in computer skills to include but not limited to, email, word, excel, TEAMS, and the organization’s telehealth platform.

  • Attends and successfully completes all required training programs; participates in ongoing conference calls, webinars, and other professional development opportunities.

  • Participates as part of a team to meet patient needs and organizational demands. Uses effective communication and collaboration across all platforms to support the mission of the organization.

  • This position supports team care, and the role is pivotal in our National Committee for Quality Assurance (NCQA) recognized patient centered health home




  • High school diploma or GED

  • BLS Certificate upon hire

  • Valid driver’s license and insurability

  • Community Health Worker Certificate within the first 12 months of employment


  • Certified Applications Counselor (CAC)

  • State Insurance Assistance Program (SHIP) Certification

  • Motivational Interviewing Certification

  • Navigator Certification

  • SOAR Certification



  • Proficient computer skills to include internet-based applications

  • Ability to perform in a fast-paced environment while managing multiple priorities

  • Ability to be well organized and accountable for time and activities with remote supervision

  • Must have a passion for serving others while adhering to and demonstrating exceptional attention to boundaries and professionalism


  • 2 years’ experience working in a health care or community service setting

  • Bachelor’s degree in Human Services, Social Work, Health Sciences


  • Communication proficiency

  • Collaboration skills

  • Customer/client focus

  • Ethical practice

  • Flexibility

  • Interpersonal skills

  • Organizational skills

  • P roblem solving/analysis

  • Stress management/composure

  • Technical proficiency


Community Health

Employment Type



$16.90-$18.91 hr/DOE