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

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

About The Position

The senior inpatient care manager coordinates complex discharge planning and provides psychosocial assessment and interventions for designated patient populations across the continuum of care. The role works with providers, other case managers, and multidisciplinary care teams to support desired patient, quality, and financial outcomes. Case managers are generally assigned to a specific campus but may be expected to float to other campuses when needed.

Requirements

MSW or equivalent, or an RN degree.
Current New Jersey social work license if working at St. Luke’s Warren Campus.
At least five years of inpatient acute care case management experience.
ACM certification; CCM certification may substitute for ACM certification for case managers grandfathered into case management through hospital acquisitions without an RN or MSW.
Care managers grandfathered through hospital acquisitions without an MSW or RN are eligible.

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 the multidisciplinary team to design discharge plans responsive to patient needs and goals.
Work with care management colleagues, support center staff, clinical coordinators, utilization management staff, providers, and leadership teams.
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 patients or families on discharge-plan status, and reevaluate and revise plans as information becomes available.
Consider palliative care, home care, 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 readmission risk scores and implement discharge interventions accordingly.
Address and monitor resource utilization and document delays as appropriate.
Coordinate 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 for patients and families adjusting to illness, hospitalization, or alternative care placement.
Facilitate decision-making in complex cases and resolve patient-care issues compassionately, using team meetings as appropriate.
Serve as a staff resource for regulatory issues related to discharge planning and psychosocial processes.
Use electronic systems to accurately document care management functions.
Maintain confidentiality of protected health information and St. Luke’s proprietary information.
Demonstrate competency in assessment, treatment range, growth and development, and communication appropriate to the age of patients treated.
Pursue educational opportunities specific to care management.
Precept new employees as needed.
Function in a clinical coordinator role in the absence of the clinical coordinator or manager, depending on the campus.
Perform other related duties as assigned.