About The Position

Responsible for acute care sites of service to assess, plan, facilitate, and integrate coordinated care for patients from preadmission or the ED through discharge. Develops a plan of care that supports post-discharge needs across the continuum. Addresses barriers, social determinants of health, high utilization of sites of service, and psychosocial and legal components affecting patients and their plans of care. Coordinates post-discharge services as applicable to patient needs, including placement, durable medical equipment, home health, personal care services, and other complex care support. Consults with multidisciplinary teams, committees, service lines, providers, and patients and families. Ensures compliance with state, federal, hospital, and TJC guidelines. Follows Case Management department standard work, including starting discharge planning on admission, timely documentation, education about the patient’s plan of care, reporting to Adult Protective Services or Child Protective Services, documentation supporting discharge planning, resource identification, and other assigned duties. The position may be filled by a BSW, MSW, or RN. BSW applicants must have a bachelor’s degree in social work or a related field and at least one year of social work experience. MSW applicants must have a master’s degree in social work or a related field and at least one year of social work experience. RN applicants must have an associate degree in nursing and at least two years of nursing experience; an advanced degree is preferred. Across these pathways, case management, home health, quality or utilization management, and community or hospital experience are preferred. BLS is preferred at hire and must be completed within three months of hire.

Requirements

  • For the BSW pathway: bachelor’s degree in social work or a related field from a recognized college or university.
  • For the BSW pathway: at least one year of social work experience.
  • For the MSW pathway: master’s degree in social work or a related field from a recognized college or university.
  • For the MSW pathway: at least one year of social work experience.
  • For the RN pathway: associate degree in nursing from a recognized college or university.
  • For the RN pathway: two or more years of nursing experience.
  • Thorough knowledge of general nursing or social work principles, methods, techniques, community resources, discharge planning processes, and state and federal laws relevant to the Case Manager role.
  • Exemplary verbal and written communication, critical thinking, interpersonal, group, leadership, and negotiation skills, with attention to detail.
  • Ability to communicate effectively with patients, families, staff, providers, service lines, and community resources to promote positive outcomes.
  • Proficiency with computers and MS Office software.
  • BLS certification is required within three months of hire.

Nice To Haves

  • Experience in case management, home health, quality or utilization management, or a community or hospital setting.
  • For the RN pathway: advanced degree such as a BSN or MSN.
  • For the RN pathway: certification in Case Management.
  • BLS certification at the time of hire.

Responsibilities

  • Assess, plan, facilitate, and integrate coordinated care for patients from preadmission or the ED through discharge.
  • Develop plans of care that support patients’ post-discharge needs across the continuum.
  • Address barriers, social determinants of health, high utilization of sites of service, and psychosocial and legal factors affecting patients and their care plans.
  • Coordinate post-discharge services, including placement, durable medical equipment, home health, personal care services, and other complex care support as applicable.
  • Consult with multidisciplinary teams, committees, service lines, providers, patients, and families.
  • Comply with state, federal, hospital, and TJC guidelines.
  • Follow Case Management department standard work, including beginning discharge planning on admission and documenting in a timely manner.
  • Educate patients about their plans of care and complete required documentation supporting discharge planning.
  • Report to Adult Protective Services or Child Protective Services when required.
  • Identify resources and perform other duties as assigned.
© 2026 Teal Labs, Inc
Privacy PolicyTerms of Service