Transitional Care Manager

In by Michele Shea

  • Full Time
  • Butte, MT
  • April 23, 2021
  • $15.16 - $18.46 per hour DOE

Website swmtchc Southwest Montana Community Health Center

Transitional Care Manager

Full-time, benefits-eligible

FLSA non-exempt

Wage DOE

Position open through 4/23/2021

SWMTCHC Core Competencies, Mission, and Vision

Integrity and Trust

Is widely trusted; is seen as a direct and truthful individual; can present the unvarnished truth in an appropriate and helpful manner; keeps confidences; admits mistakes; doesn’t misrepresent themselves for personal gain.


Maintains confidentiality of others’ personal information; can be trusted to represent the SWMTCHC outside the organization; meets and complies with all medical, regulatory, and licensing standards; takes ownership of their own actions and is accountable for their own mistakes; follows through on what they say they will do.

Mission and Vision Integration

Adheres to the Mission and Vision of the SWMTCHC during both good and bad times; is dedicated to meeting the expectations and requirements of the SWMTCHC mission and vision; acts in line with the values of the mission; practices what they preach.


To inspire hope and empower wellness by providing access to comprehensive healthcare


A stronger Montana through community and wellness


Articulates and sincerely demonstrates the mission consistently through examples such as: treating all people (patients/staff/other agencies, etc.) equally; non-judgmental; listens to others without making assumptions, uses eye contact and acknowledges others; makes decisions that are focused on the patient/staff.

Team Relations

Understands and supports the team approach; s seen as team player and is cooperative; easily gains the trust and support of peers; encourages collaboration; can be candid with peers; fosters open dialogue; creates a feeling of belonging to the team.


Effectively able to communicate (can give and receive both positive and constructive feedback) with peer group and other staff to get the message across; knows appropriate team members to consult relative to the issue or situation; willingly shares knowledge and information with appropriate team members; actively seeks opportunities to help the team.

Position Summary

The transitional care manager is a clinical liaison position between St. James Hospital and patients who seek services at the CHC and have provisional needs. The transitional care manager will provide these services by working and collaborating with the entire healthcare team at the SWMTCHC. This team includes providers, pharmacy staff, nursing staff, medical assistants, care management, behavioral health, team assistants, all clerical, financial, and medical records staff, and all supervisors. The transitional care manager will perform patient care duties in collaboration with the health care team (the medical provider is the team leader). The transitional care manager will focus on building and maintaining relationships with clients and families, discharge planners, social workers, and other facility personnel. In this role you will assess patients’ medical and social needs to identify appropriate services. Working with the SWMTCHC staff you will lead the intake/discharge processes for patients that will be leaving the hospital, entering a facility for transitional housing or long-term care, or returning home.

This position requires an individual who is able to develop and build strong, lasting relationships with referral sources, clients, and families. Excellent planning, organization and presentation skills are critical.

Position Requirements

  • One-year experience preferred in an acute, long term or ambulatory care environment or in social services
  • Demonstrated ability to problem solve
  • Working knowledge of community resources
  • Motivated, self-starter

Essential Functions, Roles, and Responsibilities (not exhaustive)

  • Daily discharge planning meetings with St. James Healthcare
  • Visiting patients in the hospital to engage them in their care with the clinic
  • Use EMR to identify any clinic referrals from SWMTCHC providers
  • Work in conjunction with SWMTCHC providers and staff to provide efficient and high-quality discharge planning for patients
  • Assessment/coordination for patients needing follow up appointments at SWMTCHC.
  • Transitional planning/liaison for patients discharging from the hospital to transitional care/long term care
  • Transitional planning/liaison for patients discharging from the transitional care to home setting
  • Complete, document, and review patient history in EMR
  • Perform Social Determinants of Health questionnaire and provide patients and families with adequate community resources
  • Willing to learn team responsibilities as needed – electronic medical record and clinic flow change over time and with performance improvement and developments in technology
  • Takes personal responsibility to understand new procedures by following direction of trainer and completing self-learning packets as available
  • Maintain tracking of referrals or collaborate with team members to ensure referral tracking completed
  • Responsible for establishing, growing, and maintaining relationships with facility-based referral sources in accordance with SWMTCHC policies and procedures, by both communicating with existing referral sources and identifying new opportunities
  • Communicates with providers and staff several times daily
  • Asks for help from other staff as needed
  • Uses courteous phone skills at all times
  • Answer patients’ questions or direct them to appropriate resource

Required Knowledge, Skills and Abilities

  • Competent in dealing with diverse populations
  • Knowledge of health record keeping and charting
  • Ability to operate a computer and job-related software
  • Excellent oral and written communication skills
  • Ability to organize and prioritize tasks
  • Ability to work under pressure
  • Strong attention to detail and problem-solving skills
  • Ability to work independently and as a team member

Supervision: This position has no supervisory responsibilities

Immediate Supervisor: Director of Behavioral Health; in their absence, designee

Physical Demands/Working Conditions:

General office/clinic conditions are pleasant; good, clean working conditions where accident and hazards are negligible; requires short periods of moderate lifting, pushing or pulling objects up to twenty pounds. Clear diction and acute hearing are necessary for effective communication with the staff and public. This position does require daily travel between the clinic and hospital.

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change, or new ones may be assigned at any time with or without notice.

Southwest Montana Community Health Center is an Equal Opportunity Employer

Benefits: Eligible employees are offered a competitive wage; full benefits package including affordable health, dental, vision, voluntary life/ADD benefits; company paid life/ADD benefit; retirement plan with company match after one year; paid vacation, sick, and holidays; great work/life balance; employee discounts on services; and more, in a pleasant and professional environment.

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