Inpatient Social Worker (MSW) or Registered Nurse (RN) Care Manager, Full Time, Anderson Campus

St. Luke's University Health Network•Easton, PA

About The Position

The Inpatient Social Worker or Registered Nurse Care Manager coordinates complex patient discharge planning and provides supportive counseling, psychosocial assessment, and interventions for designated patient populations across the continuum of care. The role works with providers, registered nurse care managers, social workers, and multidisciplinary care teams to support desired patient, quality, and financial outcomes. The position develops and revises discharge plans based on patients’ psychosocial needs, goals, and changing circumstances; collaborates with patients, families, caregivers, and care teams; manages length of stay by identifying and addressing barriers; and coordinates patient and community resources to support safe, effective transitions and reduce readmission risk. It also provides patient and family advocacy and counseling, supports complex decision-making, addresses care-related issues, advises staff on relevant regulatory and psychosocial processes, and accurately documents care management activities in electronic systems.

Requirements

For the social worker pathway: MSW or equivalent from an accredited school of social work.
For the RN pathway: graduation from a professional nursing program and current RN license to practice in Pennsylvania, or pursuit of Pennsylvania licensure through reciprocity.
For the RN pathway, BSN is required or must be obtained within three years of hire.
Knowledge of medical terminology.
Basic computer skills.
Strong critical-thinking skills and ability to maintain collaborative, effective working relationships.
Ability to assert needs to patients, families, physicians, and interdisciplinary team members while maintaining rapport and relationships.
Ability to communicate verbally and in writing.
Ability to meet the stated physical and sensory requirements, including sitting, walking, climbing stairs, driving, frequent fingering and handling, occasional gripping and manipulation, and potentially lifting, carrying, pushing, or pulling objects weighing up to 75 pounds.

Nice To Haves

At least two years of experience as an RN or social worker in an acute hospital setting is preferred.
Previous care management experience is preferred.
For the RN pathway, an advanced degree is preferred; MSN and/or Case Management Certification are preferred.
For the social worker pathway, current New Jersey social work license is required if working at St. Luke’s Warren Campus.
For the RN pathway, New Jersey RN licensure is required for Warren Campus.
If the primary coverage area is OB, membership in the National Organization of Perinatal Social Workers is required.
Per-diem BSWs currently in school and within six months of completing an MSW may be hired.

Responsibilities

Develop discharge plans that address patients’ psychosocial needs and support goals for the next step in the continuum of care.
Collaborate with patients, families or caregivers, and multidisciplinary teams to develop discharge plans responsive to patient needs and goals.
Work with care management colleagues, including RN care managers, assistants, coordinators, utilization management staff, and the director.
Facilitate communication among treatment team members.
Manage length of stay by proactively identifying and mitigating barriers to care and successful discharge.
Update the care team and patient or family on discharge-plan status, and revise plans as new information becomes available.
Consider palliative care, homecare, and other outpatient services to support patient health and reduce readmission risk.
Issue applicable state and federal regulatory notices, including IMM, MOON, and BPCI notifications.
Monitor risk assessments using available tools and implement appropriate discharge interventions.
Address and monitor resource utilization and document delays as appropriate.
Identify patients with unplanned readmissions and complete root cause analyses.
Coordinate patient and community resources to achieve safe and effective discharge plans, accomplish goals, and minimize readmission risk.
Collaborate with Outpatient Care Managers on patient handovers and post-discharge follow-up.
Provide supportive counseling and advocacy to patients and families adjusting to illness, hospitalization, or alternative care placement, and facilitate decision-making in complex cases.
Compassionately facilitate resolution of patient-care issues, using team meetings as appropriate.
Serve as a staff resource on regulatory issues related to discharge planning and psychosocial processes.
Use electronic systems to accurately document care manager functions.