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

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

About The Position

The 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.

Requirements

MSW or equivalent from an accredited school of social work, or graduation from a professional nursing program.
For the social worker pathway, a current New Jersey social work license is required if working at St. Luke’s Warren Campus.
For the RN pathway, a current license to practice in Pennsylvania or pursuit of Pennsylvania licensure through reciprocity is required; New Jersey RN licensure is required for Warren Campus.
BSN required for the RN pathway or to be obtained within three years of hire.
Strong critical thinking skills.
Ability to maintain collaborative and effective working relationships.
Ability to assert needs to patients, families, physicians, and other interdisciplinary team members while maintaining rapport and relationships.
Knowledge of medical terminology.
Ability to communicate verbally and in writing.
Basic computer skills.

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.
Advanced degree for the RN pathway.
MSN and/or Case Management Certification for the RN pathway.
For primary OB coverage, 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 goals for the next step in the continuum of care.
Collaborate with patients, families or caregivers, and multidisciplinary teams to create discharge plans responsive to patient needs and goals.
Work as part of the care management team, 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 addressing issues and barriers to care and successful discharge.
Update the care team and patients or families on discharge plan status, and revise plans as new information becomes available.
Consider palliative care, home care, and other services to support patients in outpatient settings and minimize 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 use of patient and community resources to support safe, effective discharge plans 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 as they adjust to illness, hospitalization, or alternative care placement, and facilitate decision-making in complex cases.
Facilitate compassionate resolution of patient care issues, using team meetings as appropriate.
Serve as a resource to staff on regulatory issues related to discharge planning and psychosocial processes.
Use electronic systems to accurately document care management functions.