Social Services Care Manager
Billings Clinic

Job Info

Under the direction of department leadership, social service care manager staff provide services consisting of comprehensive case management, care coordination, continuing care services, and clinical social work services including crisis intervention and emotional support within the professional's defined scope of practice. In addition, the social services care manager is responsible for providing education addressing physical, psychosocial, financial, environmental, and other needs of patients and families and/or significant others. The social services care manager is part of an interdisciplinary team who promotes health and address medical and non-medical barriers.

Essential Job Functions

• Proactively screens and assesses the acuity and transitional needs of each assigned patient.
• Identifies high risk patients through risk stratification tools and ongoing assessments including ED utilization and hospitalizations to address the medical/psychosocial/financial needs of the patients and their support systems in both ambulatory and hospital settings.
• Conducts initial and ongoing assessments and chart review to identify potential and or actual psychosocial barriers.
• Engages and collaborates with patients, family members and healthcare team to establish a care plan that addresses the mutually identified needs of the patient.
• Treats all patients with compassion and respects individual rights to self-determination.
• Coordinates patient needs between support systems, healthcare professionals, community and state agencies. Serves as a liaison between hospital, clinic and community agencies to facilitate care coordination and the exchange of clinical and referral information.
• Advocate for and assist the patient as they move across the care continuum.
• Provides information and education about available resources to patients and their support systems.
• Reinforces goals of care and treatment plans with patients and support systems in order to enhance patient and support system engagement.
• Partners with the multidisciplinary/healthcare team and the Care Management team to guide/advocate placement to the appropriate Acute rehab, LTACH, SNF, long-term care facility, assisted living facility, or Home Health Care, in-home services, hospice, ancillary OP services and/or DME as clinically appropriate and within scope of practice.
• Demonstrates and utilizes knowledge of services and resources related to the needs of the patient.
• Effectively collaborates and coordinates care needs with the care management team as appropriate for optimal patient outcomes.
• Monitors the need for revisions to the plan of care and makes recommendations to the multidisciplinary team when indicated.
• Understands consultative disciplines and their role in patient care.
• Maintains working knowledge of CMS requirements and readmission penalties.
• Maintains working knowledge of insurance/payer benefits.
• Modifies treatment plans to reflect changes in patient's progress related to the plan of care.
• Social service Care managers will ensure that assessment, interventions and goals of care are accurately documented in the patient's electronic medical record in a timely manner.
• Utilizes standards of professional practice in all documentation and communication consistent with organization/department policy as well as professional licensing boards and ethical guidelines established and universally supported by the profession.
• Documentation and patient information shall be secured and maintained in accordance with Billings Clinic policy, HIPPA, state and federal guidelines.
• Identifies service gaps and participates in organization programs to address and improve quality of care.
• Advocates for marginalized or vulnerable populations by identifying cases of abuse and neglect and appropriately involving risk management and regulatory agencies.
• Participates in continuing education, department planning, work teams and process improvement activities.
• Adheres to department and organizational policies including but not limited to confidentiality, infection control, patient rights, medical ethics, advance directives, and disaster protocol and safety.
• Demonstrates the ability to be flexible, open minded and adaptable to change.
• Maintains current licensure (where applicable).
• Utilizes standards of professional practice in all communication with patients, support systems and colleagues.
• Maintains competency in organizational and departmental policies/processes relevant to job performance.

Minimum Qualifications

Education

• 4 Year / Bachelor's Degree social work or related field; human services, sociology or psychology.

Other Minimum Qualifications

• Previous experience in health care field preferred.
• Excellent written, verbal and listening skills.
• Willingness to establish effective working relationships with internal and external customers.
• Ability to manage conflict, stress and multiple simultaneous work demands in an effective and professional manner.
• Incorporate population specific needs, from birth to geriatrics, into all aspects of communication and patient care.