Acute Rehabilitation Case Manager

St. Luke’s University Health Network; Allentown (Lehigh County); On-site; USD 60,000 - 82,000; Full time

Job summary

St. Luke’s University Health Network seeks a Discharge Planner to review rehabilitation admissions, coordinate discharge planning, and educate patients and families. The role requires collaboration with an interdisciplinary team to design safe, timely discharge plans and ensure compliance with regulatory guidelines.

The position emphasizes patient-centered care, communication, and continuity of care from hospital to community services, with engagement in daily stand-ups and weekly meetings.

Qualifications

• Two to five years of clinical healthcare experience, preferably in rehabilitation.
• MSW or RN with a related master's may be considered based on experience.
• Familiarity with discharge planning processes and regulatory guidelines (e.g., Medicare, CARF, JCAHO).

Responsibilities

• Review admissions for rehabilitation patients to identify psychosocial barriers and discharge needs.
• Assess ongoing discharge planning needs and facilitate changes for safe, timely discharge.
• Maintain documentation and ensure regulatory compliance.
• Collaborate with patient, family, and interdisciplinary team to design discharge plans.
• Educate patients and families about diagnosis, treatment, discharge plan, and life adjustments.
• Coordinate with outpatient Care Managers for handover and post-discharge follow-up.
• Participate in daily stand-up and weekly interdisciplinary team meetings.
• Arrange pre-discharge services including community resources and DME.

Skills

Discharge planning

Care coordination

Patient education

Interdisciplinary collaboration

Communication skills

Education

MSW

RN (BSN preferred)

Master's in related field (care management)

Job description

JOB DUTIES AND RESPONSIBILITIES

• Performs admission review on all rehabilitation patients that identifies psycho-social barriers, interventions to implement, and discharge planning needs to meet the desired goals for the next step in the continuum of care for the patient.
• Completes an ongoing assessments of discharge planning needs, identifies and mitigates barriers, and proactively facilitates changes to ensure a safe, timely and efficient discharge.
• Completes documentation
• Facilitates resolution of issues surrounding patient care in a compassionate, empathetic manner.
• Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis.
• Collaborates with the patient, family, or other caregivers, and interdisciplinary team to design a discharge plan respective of the patient’s needs and goals.
• Remain in contact with the patient/family at least three times per week to ensure the patient/family remains informed of the rehab process and discharge plans.
• Participates in daily “stand-up” meetings with the interdisciplinary team to briefly review patient progress and provide updates on information relevant to the patient’s plan of care.
• Participates in weekly Interdisciplinary Team Meetings for all patients which includes scheduling appropriate patients, completing documentation, and follow up with patients and families post meeting.
• Arranges for services prior to discharge to meet patient’s needs both at time of discharge, reduce readmission, and maintain a healthy long-term outlook.
• This includes but is not limited to community, state, and federal resources and DME acquisition.
• Provides appropriate assistance to complete medical paperwork.
• Provides education to patient and families around issues related to adaptation to the patient’s diagnosis, illness, treatment, discharge plan and/or life situation.
• Collaborates with outpatient Care Managers to identify patients for handover and post discharge follow-up.
• Acts as a resource to the staff for coverage issues, discharge options, community resources, and regulatory issues regarding discharge planning and psychosocial processes.
• Helps patients understand their rights regarding patient choice, medical treatment, advanced directives, and other related issues.
• Maintains clinical records of all patient contact, clinical reviews, and interventions according to hospital policy and other regulatory guidelines (i.e. Medicare, CARF, JCAHO, etc.).
• Documentation is completed in a progressional and timely manner and includes interventions, recommendations, and referrals.
• Facilitates authorizations, pre-certifications, concurrent reviews, and retro authorizations related to rehabilitation services and services pertinent to discharge planning.

PHYSICAL AND SENSORY REQUIREMENTS

• Sitting for up to 5 hours per day, 2 hours at a time.
• Standing for up to 1 hour per day, 1 hour at a time.
• Walking for up to 2 hours per day, 20 minutes at a time.
• Occasionally uses fingers to turn pages.
• Frequently uses hands to write, type, and hold charts.
• Rarely uses the hands or fingers for firm grasping or twisting/turning.
• Frequently uses upper extremities to lift and carry up to 10 pounds.
• Frequently stoops, occasionally squats, rarely reaches above shoulder level.
• Hearing as it relates to normal conversation in person or on telephone.
• Seeing as it relates to general vision, near vision, far vision, color vision, and peripheral vision.

EDUCATION

MSW, RN (BSN preferred), OR Masters in a related field of physical, occupational, or speech therapy may be considered based upon experience and knowledge of care management and discharge planning.

TRAINING AND EXPERIENCE

Preference is for at least two to five years of clinical experience in healthcare preferred, preferably in a rehabilitation hospital.

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 23,000 employees providing services at 16 campuses and 350+ outpatient sites. With annual net revenue in excess of $4 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 Premier 13 times total and eleven 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. St. Luke’s is the ONLY health care institution in the Lehigh Valley to be named a Top Workplace regionally repeating the exclusive honor for the third year in a row. Also, for the third straight year, St. Luke’s has been a Top Workplaces in the Philadelphia Region by the Philadelphia Inquirer, ranking 9th in the large employer category for 2025 and the only health care system in PA to receive this award. In 2025, St. Luke’s was recognized as a national Top Workplaces by USA Today, three years in a row, including the 3rd best health care system in the nation in 2023 and 2024. Lastly, in 2025, St. Luke’s was named a Top Workplace in New Jersey for the third year in a row.