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 Social Worker or Registered Nurse Care Manager coordinates patients’ complex discharge-planning needs 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 in collaboration with patients, families, caregivers, and the care team; addresses psychosocial needs and barriers to care; coordinates patient and community resources; and supports safe, effective transitions while minimizing readmission risk. It also provides patient and family advocacy and counseling, assists with complex decision-making, supports staff on regulatory and psychosocial discharge-planning issues, and documents care management activities electronically.

Requirements

Either an MSW or equivalent from an accredited school of social work, or graduation from a professional nursing program.
For the social work pathway, a current New Jersey social work license is required if working at St. Luke’s Warren Campus.
For the nursing pathway, an RN license current for practice in Pennsylvania, or seeking Pennsylvania licensure through reciprocity; New Jersey RN licensure is required for Warren Campus.
BSN required or to be obtained within three years of hire for the nursing pathway.
Knowledge of medical terminology.
Basic computer skills.
Ability to communicate verbally and in writing.
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.
Preference for at least two years of experience as an RN or Social Worker in an acute hospital setting.

Nice To Haves

Advanced degree preferred for the nursing pathway.
MSN and/or Case Management Certification preferred.
Previous care-management experience preferred.
If 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 addressing 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 create discharge plans that reflect 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 identifying and mitigating barriers to care and successful discharge.
Update the care team and patients or families on discharge-plan status, 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 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, effective discharge plans, achieve goals, and minimize readmission risk.
Collaborate with Outpatient Care Managers on patient handovers and post-discharge follow-up.
Provide supportive counseling and advocacy to help patients and families adjust to illness, hospitalization, or alternative care placement, and facilitate decisions in complex cases.
Resolve patient-care issues compassionately, 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.