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.