You’ll want to join Billings Clinic for our outstanding quality of care, exciting environment, interesting cases from a vast geography, advanced technology and educational opportunities. We are in the top 1% of hospitals internationally for receiving Magnet® Recognition consecutively since 2006. And you’ll want to stay at Billings Clinic for the amazing teamwork, caring atmosphere, and a culture that values kindness, safety and courage. This is an incredible place to learn and grow. Billings, Montana, is a friendly, college community in the Rocky Mountains with great schools and abundant family activities. Amazing outdoor recreation is just minutes from home. Four seasons of sunshine! You can make a difference here. About Us Billings Clinic is a community-owned, not-for-profit, Physician-led health system based in Billings with more than 4,700 employees, including over 550 physicians and non-physician providers. Our integrated organization consists of a multi-specialty group practice and a 304-bed hospital.Learn more (https://www.billingsclinic.com/about-us/) about Billings Clinic (our organization, history, mission, leadership and regional locations) and how we are recognized nationally for our exceptional quality. Your Benefits We provide a comprehensive and competitive benefits package to all full-time employees (minimum of 24 hours/week), including Medical, Dental, Vision, 403(b) Retirement Plan with employer matching, Defined Contribution Pension Plan, Paid Time Off, employee wellness program, and much more.Click here (https://www.billingsclinic.com/careers/employee-benefits/) for more information ordownload the Employee Benefits Guide (https://ncstoragemlbillings.blob.core.windows.net/public/2021%20Billings%20Clinic%20Staff%20Benefits%20Guide.pdf) . Magnet: Commitment to Nursing Excellence Billings Clinic is proud to be recognized for nursing excellence as a Magnet®-designated organization, joining only 97 other organizations worldwide that have achieved this honor four times. The re-designation process happens every four years. Click here (https://www.billingsclinic.com/campaign-landing-pages/magnet/) to learn more! Pre-Employment Requirements All new employees must complete several pre-employment requirements prior to starting. Click here (https://billingsclinic.csod.com/ats/careersite/search.aspx?site=15&c=billingsclinic) to learn more! Empaths Program Care Manager Billings Clinic (Billings Clinic Main Campus) req9067 Shift: Day Employment Status: Full-Time (.75 or greater) Hours per Pay Period: 0.80 = 64 hours (Non-Exempt) Starting Wage DOE: 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. Billings Clinic is Montana’s largest health system serving Montana, Wyoming and the western Dakotas. A not-for-profit organization led by a physician CEO, the health system is governed by a board of community members, nurses and physicians. Billings Clinic includes an integrated multi-specialty group practice, tertiary care hospital and trauma center, based in Billings, Montana. Learn more atwww.billingsclinic.com/aboutus (https://www.billingsclinic.com/about-us/) Billings Clinic is committed to being an inclusive and welcoming employer, that strives to be kind, safe, and courageous in all we do. As an equal opportunity employer, our policies and processes are designed to achieve fair and equitable treatment of all employees and job applicants. All employees and job applicants will be provided the same treatment in all aspects of the employment relationship, regardless of race, color, religion, sex, gender identity, sexual orientation, pregnancy, marital status, national origin, age, genetic information, military status, and/or disability. To ensure we provide an accessible candidate experience for prospective employees, please let us know if you need any accommodations during the recruitment process.