CARE MANAGER

Santiam Hospital & Clinics; Stayton (OR); On-site; USD 45,000 - 105,000; Full time

Benefits offered by this job

Medical, Vision and Dental Insurance

PTO and holiday pay

401(k) Retirement

Life Insurance

Long Term Disability

Tuition Assistance

Job summary

Santiam Hospital & Clinics in Stayton, OR is seeking a nurse/care coordinator to lead patient-centered discharge planning from admission through transition of care. The role focuses on early risk identification and proactive strategies to support safe discharges.

You will assess clinical needs, plan individualized discharges, and coordinate post-acute services, equipment, and follow-up care while collaborating with the care team.

Qualifications

• Licensed RN or LPN with MSW/LCSW training or certification.
• Experience in care management, discharge planning, case management, or utilization management.
• Strong understanding of care transitions, post-acute care services, and community resources.
• Excellent communication, collaboration, and critical thinking skills.

Responsibilities

• Lead comprehensive, patient-centered discharge planning from admission through transition of care.
• Identify high-risk patients early and implement proactive discharge strategies.
• Conduct holistic assessments of clinical needs, functional status, and social determinants of health.
• Develop and manage individualized discharge plans aligned with goals and resources.
• Coordinate post-acute services and community resources (home health, SNF, rehab, hospice, outpatient).
• Resolve barriers to discharge (placement, insurance, equipment, social/financial issues).
• Educate patients and families on post-acute care options and promote informed choices.
• Facilitate communication with post-acute providers and multidisciplinary teams.
• Document assessments, plans, and discharge outcomes accurately and timely.
• Coordinate DME, follow-up care, and appointments to ensure continuity.

Skills

RN license

LPN license

MSW/LCSW

Care management

Discharge planning

Post-acute care

Communication

Education

Master of Social Work (MSW) or LCSW

Job description

Job Details
Job Location: STAYTON, OR 97383
Education Level: License
Salary Range: $33.00 - $76.99
Hourly Job Shift: Day

Who You’ll Join

At Santiam Hospital & Clinics, we believe exceptional patient care starts with a supportive and inclusive work environment. We empower every team member by providing access to advanced medical technology and continuous professional development. Join our collaborative culture, where your contributions are valued and your growth is encouraged.

What You’ll Do

• Full-time (32 hours per week) position leading comprehensive, patient-centered discharge planning beginning at admission and continuing through transition of care.
• Identify high-risk patients early and implement proactive strategies to support safe discharge planning and reduce adverse outcomes
• Perform holistic assessments of clinical needs, functional status, support systems, home environment, and social determinants of health (SDOH)
• Develop and manage individualized discharge plans aligned with patient goals, clinical needs, and available resources
• Coordinate post-acute services and community resources, including home health, skilled nursing, rehabilitation, hospice, and outpatient care
• Proactively identify and resolve barriers to discharge, including placement challenges, insurance authorization, equipment needs, and social or financial concerns
• Support informed patient choice by educating patients and families on post-acute care options and available services
• Facilitate seamless care transitions, ensuring timely communication with post-acute providers, outpatient teams, and community partners
• Participate in multidisciplinary rounds, providing clear updates on discharge readiness, barriers, and next steps
• Ensure accurate, timely, and compliant documentation of assessments, plans, and discharge outcomes
• Coordinate durable medical equipment (DME), follow-up care, and appointments prior to discharge to promote continuity of care
• Support patient and caregiver education, reinforcing discharge instructions and promoting understanding of care plans
• Monitor utilization and length of stay, supporting efficient throughput and appropriate level-of-care decisions

Qualifications

What You’ll Need

Required:

• Licensed Registered Nurse (RN)
• Licensed Practical Nurse (LPN)
• Master of Social Work (MSW) or Licensed Clinical Social Worker (LCSW)
• Experience in care management, discharge planning, case management, or utilization management
• Strong understanding of care transitions, post-acute care services, and community resources
• Excellent communication, collaboration, and critical thinking skills
• Ability to manage multiple priorities in a fast-paced acute care environment

Preferred:

• Prior experience in acute care case management or hospital-based care coordination
• Case Management certification (e.g., CCM, ACM)
• Experience working with complex patients, high-risk populations, or social determinants of health barriers
• Familiarity with regulatory and accreditation standards related to discharge planning and transitions of care

Benefits for Eligible Positions

• Medical, Vision and Dental Insurance
• PTO and holiday pay
• Employee Referral Program
• 401(k) Retirement
• Life Insurance
• Long Term Disability
• Employee Discounts
• Bilingual Pay Differential for eligible positions
• Public Service Loan Forgiveness for eligible positions
• Tuition Assistance for eligible positions

Why Santiam Hospital?

At Santiam Hospital & Clinics, we pride ourselves on fostering a supportive and inclusive work environment where every team member is valued and empowered to make a difference. Our commitment to excellence in patient care is matched by our dedication to employee growth and well-being. As part of our team, you’ll have access to cutting-edge medical technology, ongoing professional development opportunities, and a collaborative culture that encourages innovation and teamwork. Join us at Santiam Hospital & Clinics, where your skills and compassion will be appreciated, and together, we can make a positive impact on the health and lives of our community.

With 12 clinics offering 8 specialties, you’ll be part of a diverse and dynamic healthcare community. We’re proud to have been named the 2025 Best Place to Have a Baby, Best Hospital as well as receiving accolades for our Surgery Center, Medical Facility and Women’s Clinic, reflecting our unwavering commitment to providing exceptional care for our patients.

Santiam Hospital & Clinics is a drug-free workplace in accordance with the Drug-Free Workplace Act of 1988 and an EEO affirmative action Race/Sex/Sexual Orientation/Gender Identity/National Origin/Veteran/Disability Employer.

All communication will exclusively originate from an @santiamhospital.org email address. For your security, please do not respond to messages from any other email domain.