Social Services Advocate & Case Manager - (CAH)

• Minimum current LPN license with authorization to practice nursing within the state of Montana, or current Montana RN license or a multi-state compact license with authorization to practice nursing within the state of Montana

• Minimum 2 years of nursing or care coordination experience in a hospital, clinic, long-term care, or similar medical setting preferred.

• Previous case management, discharge planning, utilization review, or social services experience preferred

• Experience working with community resources, insurance requirements, and post-acute services preferred

• RQI Provider within 7 days hire/transfer or before independent patient care, whichever comes first.

• Case Management Certification preferred.

• Promotes excellence through setting high standards and providing high quality outcomes.

• Ability to act with integrity, kindness, and exhibit empathy.

• Excellent organizational skills, detail-oriented, a self-starter, possess critical thinking skills and be able to set priorities and function as part of a team as well as independently.

• Commitment to working in a team environment and maintaining confidentiality as needed.

• Excellent verbal and written communication skills including the ability to communicate effectively with various audiences.

• Excellent interpersonal skills with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.

• Possess and maintain computer skills to include working knowledge of Microsoft Office Suite and ability to learn other software as needed.

Job Specific Duties:

• Assess patient clinical, psychosocial, financial, environmental, and discharge planning needs

• Identify barriers related to social determinants of health, access to care, caregiver support, transportation, housing, substance use, behavioral health, guardianship, legal concerns, and end-of-life planning

• Develop and coordinate safe discharge and transition plans to the least restrictive level of care appropriate to patient needs

• Collaborate with the interdisciplinary team to reduce avoidable readmissions and improve patient outcomes

• Coordinate referrals to community agencies, home health, hospice, durable medical equipment, skilled nursing, rehabilitation, behavioral health, and other post-acute services

• Serve as a resource to patients, families, providers, and staff regarding payer requirements, community resources, and discharge options

• Ensure timely communication with patients and support persons so they remain informed and actively involved in care decisions

• Advocate for patient rights, informed decision-making, self-determination, confidentiality, and access to supportive services

• Assist with utilization awareness by obtaining required documentation, provider orders, and medical necessity information as applicable to scope and department processes

• Maintain accurate, timely, and thorough documentation in the electronic medical record

• Participate in interdisciplinary rounds, discharge planning meetings, family conferences, and community partner communication

• Support care coordination efforts for swing bed, observation, emergency department, acute care, and transfer patients as applicable

• Identify opportunities for process improvement related to discharge planning, resource utilization, and patient flow

• Respond positively and professionally to changing patient volumes and departmental priorities

The above essential functions are representative of major duties of positions in this job classification.  Specific duties and responsibilities may vary based upon departmental needs.  Other duties may be assigned similar to the above consistent with knowledge, skills and abilities required for the job.  Not all of the duties may be assigned to a position.