MOMS Social Services Care Manager

This position is funded under a Federal grant that is scheduled to end on 9/29/2024.

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 2PM 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