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

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

6d•Onsite

About The Position

The Inpatient Social Worker or Registered Nurse Care Manager coordinates complex 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 updates discharge plans in collaboration with patients, families, caregivers, and care teams; identifies and mitigates barriers to care and discharge; supports appropriate resource use; and helps coordinate safe transitions and post-discharge follow-up. It also provides patient and family advocacy and counseling, facilitates decision-making in complex cases, supports resolution of care issues, and documents care management functions 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 licensure to practice in Pennsylvania, or seeking Pennsylvania licensure through reciprocity.
NJ social work licensure is required if working at St. Luke’s Warren Campus.
NJ RN licensure is required for the Warren Campus.
If the primary coverage area is OB, membership in the National Organization of Perinatal Social Workers is required.
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.
Verbal and written communication skills.
Basic computer skills.

Nice To Haves

Preference for at least two years of experience as an RN or social worker in an acute hospital setting.
Previous care management experience is preferred.
For the RN pathway, an advanced degree is preferred.
For the RN pathway, BSN is required or must be obtained within three years of hire; MSN and/or case management certification is preferred.

Responsibilities

Develop discharge plans addressing 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 suited to patient needs and goals.
Work with other care management team members, 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 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 patient and community resources to support safe and effective discharge plans, achieve goals, and minimize readmission risk.
Collaborate with Outpatient Care Managers to identify patients for handover and post-discharge follow-up.
Provide supportive counseling and advocacy to patients and families addressing adjustment to illness, hospitalization, or alternative care placement; 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 document care manager functions accurately.