Social Services Advocate & Case Manager - (CAH)

Logan Health•Chester, MT

11d•Onsite

About The Position

Coordinates clinical and social needs across the care continuum to support safe discharge, reduce re-admissions, and connect patients with appropriate resources in the Critical Access Hospital setting. Supports the organization in fulfilling the mission, vision, and values of Logan Health. Our Mission: Quality, compassionate care for all. Our Vision: Reimagine health care through connection, service and innovation. Our Core Values: Be Kind | Trust and Be Trusted | Work Together | Strive for Excellence.

Requirements

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

Nice To Haves

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
Case Management Certification preferred.

Responsibilities

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