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

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

About The Position

The Social Worker or Registered Nurse Care Manager coordinates complex discharge planning for patients 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 care manager develops and revises discharge plans in collaboration with patients, families, caregivers, and the care team; identifies barriers to care and discharge; coordinates patient and community resources; and supports safe transitions that reduce readmission risk. The role also provides counseling and advocacy, facilitates decision-making and communication, addresses care-related issues, supports regulatory compliance, and documents care manager functions in electronic systems.

Requirements

For the social work pathway: MSW or equivalent from an accredited school of social work.
For the nursing pathway: graduate of a professional nursing program and current RN license to practice in Pennsylvania, or seeking Pennsylvania licensure through reciprocity; New Jersey RN licensure is required for the Warren Campus.
BSN required for the nursing pathway, or must be obtained within three years of hire.
Current New Jersey social work license is required if working at St. Luke’s Warren Campus.
Membership in the National Organization of Perinatal Social Workers is required if the primary coverage area is OB.
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.
Ability to meet the physical and sensory requirements: sitting for one to two hours at a time; walking on all surfaces for up to five hours per day; climbing stairs; driving a car; frequent fingering and handling of objects; occasional firm grasping, twisting, and turning; occasional stooping, bending, squatting, kneeling, and reaching above shoulder level; and potentially lifting, carrying, pushing, or pulling objects up to 75 pounds. Must be able to hear normal conversations and high and low frequencies and use touch for telephone and keyboard tasks.

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 nursing pathway, an advanced degree is preferred.
For the nursing pathway, an MSN and/or Case Management Certification is preferred.

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 that reflect patient needs and goals.
Work with 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 addressing barriers to care and successful discharge proactively.
Update the care team and patients or families on discharge-plan status, and revise plans as additional information becomes available.
Consider palliative care, home care, and other outpatient services to support patient health and minimize readmissions.
Issue applicable state and federal regulatory notices, such as 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, achievement of goals, and reduced readmission risk.
Collaborate with Outpatient Care Managers to identify patients for handover 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.
Facilitate compassionate 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.