Care Manager

2 weeks ago

Allentown, Pennsylvania, United States ST. LUKE'S UNIVERSITY HEALTH NETWORK Full time
Job Summary

St. Luke's University Health Network is seeking a skilled Care Manager - Social Worker to join our team. As a key member of our care management team, you will play a vital role in coordinating the complex discharge planning needs of patients, providing supportive counseling, and facilitating the achievement of desired patient, quality, and financial outcomes.

Key Responsibilities
  • Develop and implement discharge plans that address the psycho-social needs of patients, ensuring a smooth transition to the next level of care.
  • Collaborate with patients, families, caregivers, and multidisciplinary teams to design and implement discharge plans that meet the unique needs and goals of each patient.
  • Facilitate communication among treatment team members, ensuring seamless coordination of care.
  • Proactively identify and mitigate issues and barriers to care, minimizing the risk of readmissions.
  • Monitor and update the care team and patients/families on the status of discharge plans, revising plans as necessary.
  • Consider options for palliative care, homecare, and other services to keep patients healthy and minimize the risk of readmissions.
  • Issue applicable state/federal regulatory notices, such as the Important Message from Medicare (IMM) and Medicare Outpatient Observation Notice (MOON).
  • Monitor risk assessment using available tools and implement discharge interventions accordingly.
  • Actively address and monitor resource utilization, documenting delays as necessary.
  • Identify patients with unplanned readmissions and complete root cause analysis.
  • Coordinate the utilization of patient and community resources to facilitate a safe and effective discharge plan and minimize the risk of readmission.
  • Collaborate with Outpatient Care Managers to identify patients for handover and post-discharge follow-up.
  • Provide supportive counseling and advocacy to assist patients and/or families with adjustment associated with illness, hospitalization, and/or alternative care placement.
  • Facilitate the decision-making process in complex cases, ensuring that patients and families are fully informed and engaged in their care.
  • Act as a resource to staff for regulatory issues related to discharge planning and psychosocial processes.
  • Utilize electronic systems to accurately document care manager functions.
Requirements
  • MSW or equivalent from an accredited school of social work, or a graduate of a professional nursing program with a current RN license to practice in the State of Pennsylvania or seeking Pennsylvania licensure through reciprocity.
  • At least two years of experience as an RN or Social Worker in an acute hospital setting, with previous care management experience preferred.
  • Strong critical thinking skills, ability to maintain collaborative and effective working relationships, and ability to assert needs to patients, families, physicians, and other members of the interdisciplinary team.
  • Knowledge of medical terminology, ability to communicate verbally and in written forms, and basic computer skills.
Physical and Sensory Requirements

Sitting for one to two hours at a time, walking on all surfaces for up to five hours a day, and climbing stairs. Must be capable of driving a car and have the ability to finger and handle objects frequently. Occasionally firmly grasp, twist, and turn objects with hands and fingers. May be required to lift, carry, push, and/or pull objects weighing up to 75 pounds. Occasionally stoops, bends, squats, kneels, and reaches above shoulder level. Staff must have the ability to hear as it relates to normal conversations and high and low frequencies and to touch as related to telephone and computer keyboard.

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