CARE MGR - SOCIAL WRKR - INPAT & ED

Brattleboro Memorial Hospital•Brattleboro, VT

11d•Onsite

About The Position

In accordance with Care Management, Discharge Planning, and Social Service policies, the Care Manager performs comprehensive psychosocial and functional assessments, care coordination, and discharge planning to ensure timely, safe, and patient-centered transitions of care. The Care Manager monitors and coordinates the plan of care; identifies and evaluates patients’ individual medical, psychosocial, and social determinants of health needs; and assists patients, families, and healthcare professionals in addressing those needs and developing appropriate plans for post-hospital care. The Care Manager proactively links patients to community-based services and supports to reduce avoidable hospital days and readmissions. This role provides education, advocacy, counseling, and resource coordination, addressing both clinical and psychosocial barriers that delay discharge and impact long-term wellness. The Care Manager serves as a resource to patients, families, hospital staff, medical providers, and community partners by facilitating timely access to community services, coordinating complex post-acute care needs, and resolving non-clinical barriers to discharge. Through early intervention, interdisciplinary collaboration, and effective community linkage, the Care Manager plays a key role in reducing length of stay, improving emergency department flow, optimizing inpatient throughput, and promoting optimal patient outcomes.

Requirements

Bachelor’s degree in social work required. Master’s in social work preferred.
Minimum of two (2) years of experience in care management, discharge planning, or related field preferred.
Vermont LSW required (LICSW or MSW preferred).
Must remain current with continuing education and licensure requirements.
Strong communication, critical thinking, and problem-solving skills.
Strong critical thinking and psychosocial assessment skills
Ability to work independently and collaboratively within an interdisciplinary team.
Proficiency with EHR care management documentation and data tracking.
Knowledge of medical terminology, discharge planning, and community resource navigation.
Excellent written/verbal communication for coordination with multidisciplinary teams and payers.
Ability to manage multiple priorities in a dynamic environment.
Compassionate, patient-centered approach to care.

Nice To Haves

Case Management Certification preferred.
Experience in acute care, public health, or behavioral health is strongly preferred.

Responsibilities

Conducts comprehensive assessments addressing medical, psychosocial, functional, and SDOH needs to identify barriers to discharge and long-term stability.
Collaborates with the interdisciplinary team to develop, implement, and evaluate individualized plans of care and discharge plans.
Provides patient and family with available resources and post-discharge care options.
Coordinates with insurance payers, post-acute providers, and community agencies to ensure appropriate level of care and resource access.
Serves as liaison and advocate for patients and families, ensuring communication of patient preferences and goals.
Utilizes critical thinking to evaluate patient status, progress, and potential for safe discharge.
Provides psychosocial support and crisis intervention for patients and families experiencing acute stress, loss, or complex medical and social issues.
Identifies and reports suspected abuse, neglect, or exploitation per regulatory requirements.
Participates in daily interdisciplinary rounds and huddles to support real-time discharge planning and barrier resolution.
Collaborates with external partners (e.g., primary care providers, home health, skilled nursing, behavioral health agencies) to coordinate and facilitate continuity of care.
Documents assessments, plans, and interventions in the electronic health record (EHR) timely and accurately.
Participates in quality improvement initiatives, data collection, and departmental performance activities.
Demonstrates knowledge of community resources, entitlement programs, and financial assistance options.
Adheres to standards of professional practice and ethical conduct.
Performs other duties as assigned.