St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care. The Registered Nurse or Social Worker Care Manager is responsible for coordinating the complex discharge planning needs of patients, as well as to provide supportive counseling, psycho-social assessment, and interventions for designated patient populations across the continuum of care. Also works with the providers, registered nurse care managers, social workers, and multi-disciplinary care teams to facilitate the achievement of desired patient, quality, and financial outcomes. JOB DUTIES AND RESPONSIBILITIES: Assesses the patient’s needs, goals, and barriers in relation to the patient’s clinical condition, psychosocial environment, and socioeconomic resources. Collaborates with the multidisciplinary team to plan, implement and evaluate the patient’s plan of care via daily rounds. Collaborates with the patient, family or other caregivers, and multidisciplinary team to design a discharge plan respective of the patient’s needs and goals. Re-evaluates and revises discharge plan of care as additional information is obtained or goals change. Facilitate 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; monitor GMLOS, daily LOS. Monitor risk assessment via LACE and implement discharge interventions accordingly. Identify patients with an unplanned readmission and complete root cause analysis. Collaborate with Outpatient Care Managers to identify patients for hand-off and post discharge follow up. Assures compliance with regulatory and payer source requirements. Issues applicable state/federal regulatory notices as applicable: Important Message from Medicare and Medicare Outpatient Observation Notice. Collaborates with the business office, utilization review staff, denials management and physician advisors in order to communicate medical necessity/insurance information to the multidisciplinary team. Actively addresses and monitors resource utilization and documents avoidable delays/days. Arrange for post discharge needs as appropriate, including but not limited to, DME, HHC, transportation, prescriptions, and follow up appointments. Uses electronic systems to accurately document care management functions. PHYSICAL AND SENSORY REQUIREMENTS: Sitting for one to two hours at a time, walk on all surfaces for up to five hours a day, and climb 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. EDUCATION: 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. If primary coverage area is OB, membership in the National Organization of Perinatal Social Workers is required. OR: 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. TRAINING AND EXPERIENCE: 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. Ability to maintain collaborative and effective working relationships. Able to assert needs to patients, families, physicians, and other members of the interdisciplinary team while maintaining established rapport and relationships. Knowledge of medical terminology required. Ability to communicate both verbally and in written forms. Basic computer skills required. Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!! St. Luke's University Health Network is an Equal Opportunity Employer. Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 20,000 employees providing services at 15 campuses and 300 outpatient sites. With annual net revenue of $3.5 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Fortune/Merative 11 times total and eight years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY. In 2021, St. Luke’s was identified as one of the 15 Top Health Systems nationally. SLUHN has been named a Top Workplaces 2023 by the Morning Call. In addition, St. Luke’s has been named a Top Workplace nationally, in the Philadelphia region, and in New Jersey. St. Luke’s is the ONLY healthcare institution in Pennsylvania and the third-highest ranked healthcare entity in the nation to be deemed a Top Workplace in 2023. In 2023, St. Luke’s was named one of America’s Best Employers for Women by Forbes. St. Luke’s was the only employer in the Lehigh Valley to be named to the list and was one of only two healthcare employers in Pennsylvania to receive the designation. St. Luke’s University Health Network is the top-ranked Lehigh Valley-based employer in Forbes Magazine’s ranking of employers in Pennsylvania. Learn More Here.