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Job Description:

Responsible for assessment, care coordination, discharge planning, and post-acute referrals for patients with complex medical and/or social determinants of health needs in the acute hospital setting.

• **Essential Functions**

+ Assessment: Identifies patients using screening criteria and conduct comprehensive evaluations.

+ Care Planning: Develops, adjusts, and coordinates care plans to address medical and social needs.

+ Patient Support: Guides self-management using motivational interviewing and coaching.

+ Education & Advocacy: Provides education to healthcare teams and patients, advocate for patient rights, and support self-care.

+ Collaboration: Works with multidisciplinary teams to ensure timely, high-quality care.

+ Process Improvement: Leads initiatives to enhance care transitions and policy adherence.

+ Advanced Care Planning: Provides Goals of Care education for informed decision-making.

+ Data Analysis & Compliance: Tracks key metrics, analyze trends, and ensure regulatory compliance.

Skills

+ Assessment

+ Care Planning

+ Motivational Interviewing

+ Critical Thinking

+ Time Management

+ Customer Service

+ Patient Education

+ Communication

+ Prioritization

Minimum Qualifications

+ Current Registered Nurse (RN) license in state of practice.

+ Bachelor of Science in Nursing (BSN) from an accredited institution (degree verification required). RNs hired or promoted into this role must obtain their BSN within four (4) years of their hire or promotion date. If there is an existing education agreement, that agreement will take precedence.

+ Demonstrated clinical nursing experience in an inpatient hospital setting, and familiarity with hospital patient-related terminology and processes.

+ Demonstrated understanding of disease management including treatment, length of stay, identifying barriers to delivery of care and any variation.

Preferred Qualification

+ Bachelor of Science in Nursing (BSN) from an accredited institution.

+ Case Management Certification

+ Demonstrated experience in case management, utilization review, value-based care, and/or discharge planning.

+ Basic computer skills, including proficiency in word processing and spreadsheet software. Intermediate knowledge of word processing and Excel software.

For Social Work Candidate:

+ Master of Social Work (MSW) from an accredited institution (degree verification required).

+ Current state licensure, as applicable, is obtained prior to or upon completion of required supervision hours.

+ Basic computer proficiency, including familiarity with word processing and spreadsheet software.

+ Strong written and verbal communication skills.

+ Demonstrated ability to apply critical thinking skills.

Physical Requirements:

• Ongoing need for employee to see and read

information, documents, monitors, identify

equipment and supplies, and be able to assess

customer needs.

• Frequent interactions with providers,

colleagues, customers, patients/clients, and

visitors that require employee to verbally

communicate as well as hear and understand

spoken information, needs, and issues quickly

and accurately.

• Manual dexterity of hands and fingers to

manipulate complex and delicate equipment

with precision and accuracy. This includes

frequent computer use for typing, accessing

needed information, etc.

Location:

Intermountain Health St Vincent Regional Hospital

Work City:

Billings

Work State:

Montana

Scheduled Weekly Hours:

0

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$40.39 - $60.96

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits package here (https://intermountainhealthcare.org/careers/benefits) .

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

At Intermountain Health, we use the artificial intelligence ("AI") platform, HiredScore to improve your job application experience. HiredScore helps match your skills and experiences to the best jobs for you. While HiredScore assists in reviewing applications, all final decisions are made by Intermountain personnel to ensure fairness. We protect your privacy and follow strict data protection rules. Your information is safe and used only for recruitment. Thank you for considering a career with us and experiencing our AI-enhanced recruitment process.

All positions subject to close without notice.