This position is 100% grant-funded and is subject to termination at any time due to funding availability. Though Billings Clinic intends to receive extended grant funding to maintain the position, this position cannot be guaranteed past 06/30/2026. 

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

• 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.
• Advocates for and assists the patient as they move across the care continuum
• Treats all patients with compassion and respects individual rights to self-determination
• The responsibilities of the SW care manager are listed below, in order of priority and intended to ensure effective prioritization of tasks.

Priority 1: Reviews New Patients for Psychosocial Needs
Reviews Cerner census and ensures all patients are accounted for on assigned floor
Meets with unit assigned Care Manager at the beginning of every shift to determine which patients have complex psychosocial needs requiring social work assessment and discharge planning interventions
Collaborates with Care Manager to evaluate patients with psychosocial needs, including but not limited to, patients with the following needs:
Psychosocial Assessment
Crisis intervention/Trauma
Adjustment to illness/new diagnosis
Grief & bereavement, end-of-life concerns
Chronic substance abuse (assessment and referral)
Abuse and/or neglect (consultation)
Sexual assault
Advance Directives
Self-pay
Competency concerns
Homeless/Unsafe discharge
Guardianship/Adoption
Mental health/behavioral issues
Patients admitted from Skilled Nursing Facilities or Alternative Living Facilities
The Women’s Center – mother and/or baby issues
Identifies patients and families needing support for emotional, social, and financial consequences of illness and/or disabilities
Accesses and mobilizes family and/or community resources to meet identified needs
Collaborates with the Palliative Care Team related to treatment, end-of-life decisions, and bereavement
Educates and communicates with multi-disciplinary team on any social, emotional, cultural, environmental, economic, and/or supportive care needs for targeted patients

Priority 2: Initiates and Coordinates Discharge Planning for Assigned Patients
Collaborates with Care Managers for resolution of complex patient problems and coordinates community resources as needed, to achieve desired treatment outcomes
Participates in discharge planning activities for complex patients, to ensure a timely discharge and to provide appropriate linkage with care providers, post-discharge
Intervenes with families exhibiting complex family dynamics which impact directly on patient care and plan for discharge
Communicates with Care Managers regarding the discharge planning status of all patients referred to Social Work
Notifies Care Management Department of newly identified resources or change in previously identified resources
Utilizes proactive discharge planning to engage the patient/family/caregiver in the development and implementation of the discharge plan
Discusses patient’s discharge plan and needs with the care team
Documents discharge plan, patient’s and/or patient’s representative understanding of the plan, and their input to the plan, including refusal of discharge plan
Educates patient or patient representative regarding post-acute options, obtains a minimum of 3 choices for post-acute services, and documents choices per policy
Ensures authorization is obtained for post-discharge services, if required; follows-up with facility and/or payer daily, if authorization is not obtained within 24 hours
Contacts referral agencies to make post discharge arrangements for patients, including verification of bed availability
Confirms actual and projected discharge dates with patient, family, and/or patient representatives; ensures transportation is arranged
Updates post-acute providers of patient’s discharge condition and final discharge plans
Reassesses and documents discharge needs throughout the patient stay at minimum every 3 days, or as patient condition changes; communicates changes with patient and/or patient representative

Priority 3: Attends MDRs, Department Meetings, and Additional Trainings
Attends MDRs on assigned units
Identifies anticipated discharge date for assigned patients
Attends 1400 afternoon huddles with charge nurse and nurse care manager to ensure action items from MDRs have been completed; escalates barriers to supervisor
Presents and discusses transition plans of assigned patients at MDRs
Provides Care Management Department Supervisor and/or Managers timely follow-up of action items discussed at MDRs before end of shift
Attends departmental meetings and/or trainings as scheduled

Priority 4: Leads Patient-Family Conferences
Assesses needs for discussion with patient, family, physician and care team regarding patient’s care or discharge plan
Schedules and leads patient care conferences to resolve issues and provide clarification to patient, physician, and family

Priority 5: Escalates Barriers as Appropriate
Discusses barriers to discharge with attending physician and/or multi-disciplinary team; if unsuccessful or unable to resolve issues, escalates to Supervisor, Manager, or Director
• Insurance and Utilization Management
Maintains working knowledge of CMS requirements and readmission penalties
Maintains working knowledge of insurance/payer benefit
• Documentation
Documents accurately and in a timely manner in the Electronic Medical Record per program guidelines
Utilizes standards of professional practice in all documentation and communication consistent with organization/department policy as well as the Board of Nursing and ethical guidelines established and universally supported by the nursing profession
Assures documentation and patient information is secure and maintained in accordance with Billings Clinic policy, HIPPA, state and federal guidelines
• Professional Accountabilities
Participates in continuing education, department planning, work teams and process improvement activities
Maintains current Licensure
Adheres to department and organizational policies addressing confidentiality, infection control, patient rights, medical ethics, advance directives, disaster protocols and safety
Demonstrates the ability to be flexible, open minded and adaptable to change
Maintains competency in organizational and departmental policies/processes relevant to job performance
Utilizes standards of professional practice in all communication with patients, support systems and colleagues consistent with the Board of Nursing and ethical guidelines established and universally supported by the nursing profession
Performs all other duties as assigned or as needed to meet the needs of the department/organization

Minimum Qualifications

Education
• 4 year Bachelor's Degree in social work or related field; human services, sociology or psychology.

Experience
• 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.

Or an equivalent combination of education and experience relating to the above tasks, knowledge, skills and abilities will be considered. Employees that require a licensed or certification must be properly licensed/certified and the licensure/certification must be in good standing.