Social Services Care Manager

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

Knowledge, Skills, and Abilities

• Billings Clinic policy and procedures, both organizational and departmental

• Personal computers, hardware and software

• Billings Clinic Code of Business Conduct

• Billings Clinic Corporate Compliance Program

• HIPAA and confidentiality requirements

• Patient’s/resident’s rights

• Customer service techniques and Personal Service Excellence (PSE)

• Fiscal management

• Health care reimbursement

• Utilization review

• Care coordination planning

• Human services theories, principles and practices

• Community agencies and resources

• Process improvement principles

• Change management principles

• Group dynamics         

• Advanced professional communication skills, both verbal and written    

• Conflict resolution

• Critical thinking and analytic skills necessary to perform essential job functions

• Identifying problems and researching and recommending solutions

• Establishing and maintaining effective working relationships with patients, staff and public

• Leadership skills to facilitate teams and to bring about desired change  

• Incorporate population specific needs into all aspects of communication and patient care; scope of services provided will encompass age groups from infant through geriatric      

• Communicate clearly and effectively, both verbal and written

• Establish and maintain collaborative relationships

• Adequate manual and finger dexterity required to perform appropriate procedures, write legibly, and utilize current technological devices

• Adequate visual acuity required to read and interpret information to perform essential job functions

• Adequate hearing and verbal communication skills to perform essential job functions and interact with patients, support systems and other health care providers         

• Work independently    

• Understand and apply clinical, financial and reimbursement information

• Interpret, adapt and apply guidelines and procedures

• Works with a variety of diverse and complex patients and support systems

• Interacts with internal and external health care providers, agencies and facilities

• Perform tasks or duties with frequent interruptions and changing priorities           

• Lift, bend, stretch and reach to accomplish duties                     

• Position requires ability to define and implement an evolving role of patient centered care delivered in a complex integrated health care system which includes setting common goals, merging resources, providing education, and cross training of roles.

• Must be able to work with a variety of diverse and complex patients, support systems, internal and external health care providers, agencies and facilities.

• Must be able to function autonomously and with a high degree of flexibility