Inpatient Registered Nurse or Social Worker Care Manager coordinating discharge planning and psycho-social interventions. Working with interdisciplinary teams to facilitate patient outcome and care management.
Responsibilities
Assess the patient’s needs, goals, and barriers in relation to the patient’s clinical condition, psychosocial environment, and socioeconomic resources
Collaborate with the multidisciplinary team to plan, implement and evaluate the patient’s plan of care through rounding or other methods
Collaborate with the patient, family or other caregivers, and multidisciplinary team to design a discharge plan respective of the patient’s needs and goals
Re-evaluate and revise discharge plan of care as additional information is obtained or goals change
Proactively considers options such as palliative care, home care and other services that work to keep the patient as healthy as possible in the outpatient setting, minimizing the risk of re-admissions
Works as a team with other members of care management, including but not limited to: Social workers, assistants, coordinators, utilization management staff, and director
Facilitates communication among all treatment team members
Manages length of stay by proactively identifying and mitigating issues and barriers to care and a successful discharge plan
Monitors risk assessment using available tools and implements discharge interventions accordingly, minimizing risk of readmission
Identifies patients with an unplanned readmission and completes root cause analysis
Collaborates with Outpatient Care Managers to identify patients for handover and post discharge follow up
Requirements
MSW or equivalent from an accredited school of social work
Current NJ SW license if working at St. Luke’s Warren Campus
May hire per diem BSW’s currently in school within 6 months of completing MSW
Graduate of professional nursing program
Registered Nurse with current license to practice in the State of Pennsylvania or seeking Pennsylvania licensure through reciprocity
NJ RN licensure required for Warren Campus
Advanced degree preferred
BSN required or obtained within 3 years of hire, MSN and/or Case Management Certification preferred
Preference is for at least two years of experience as an RN or Social Worker in an acute hospital setting
Previous care management experience is preferred
Strong critical thinking skills
Knowledge of medical terminology required
Basic computer skills required
Benefits
Health insurance
Flexible working hours
Paid time off
Professional development opportunities
Job title
Inpatient Registered Nurse, Social Worker (MSW), Care Manager
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