The Care Management Coordinator is responsible for ensuring the patients of South Big Horn Critical Access Hospital receive needed services in a supportive, effective, efficient, timely, and cost-effective manner while maintaining the highest practicable physical, mental, and psychosocial wellbeing.

The Care Management Coordinator assesses patients’ needs, creates personalized plans of care, and will guide facility staff in matters of patient advocacy, protection, and promotion of rights.

This position will maintain compliance with state and federal regulations and ensure the highest standards of professional patient care practices, consistency, continuity, and coordination, are met.

ESSENTIAL JOB FUNCTIONS:

• Must assess and collect data to evaluate current records and pertinent social data concerning personal and family problems medically related to patient's illness and care shall be maintained in each patient's record.
• Gather information and conduct preadmission screening of individuals seeking admission to the facility via the swing bed program.
• Complete and update assessments for assigned patients as part of the comprehensive assessment process. Assessments must identify patients with current needs for social service and other interventions to improve or maintain functional abilities and those patients at risk of psychosocial deterioration.
• Links patients with identified needs to social services programs and entitlements such as transportation assistance and translation services.
• Interview patients interested family members, legal representatives, and significant others to obtain and update information needed to develop individualized plans of care to protect and promote residents' rights.
• In consultation with the inter-department disciplinary team, will develop, implement, follow, and monitor admission and discharge planning and patient care plans and the services associated with each resident.
• Complete prior authorizations and work with insurance carriers to assist patients with obtaining coverage of services, when needed.
• Assist patients with completing Medicare/Medicaid applications.
• Maintain records of care management activities.
• Audits clinical records of patients on a regular basis to identify concerns about patient rights.
• Provides social service visits as needed to attain or maintain the highest practicable mental and psychosocial well-being of patients.
• Identifies ways to accommodate swing bed patient choices, preferences, and customary routines. Includes these approaches in plan of care.
• Shall create, implement, and maintain policies related to care management and confidentiality of patients within the facility.
• Gives patients, family members and legal representatives information about their rights to make choices about healthcare decisions and about eligibility for Medicare and Medicaid benefits.
• Will act as a liaison with community resources for legal, financial, mortuary, social, health and communities' agencies and other services. Assists with applications for benefits and procurement of services, clothing, personal care items from community sources outside the facility.
• With the consent of patients, maintains ongoing contact with family members and/or legal representatives regarding changes in condition, discharge planning efforts and to encourage family participation in developing plans of care.
• Completes reporting requirements as required by government agencies.
• Assists in the preparation and participation of State surveys during annual reviews and special cite visits.

MINIMUM QUALIFICATION STANDARDS:

Education:       Bachelor’s degree in social work or bachelor’s degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling or psychology from an accredited institution.

Licensure:        None

Work Experience:       Minimum 1-year supervised social services experience in a health care setting working directly with individuals.

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