Care Transition & Discharge Coordinator (MSW/RN)

St. Luke’s University Health Network; Allentown (Lehigh County); On-site; USD 65,000 - 85,000; Full time

Job summary

St. Luke’s University Health Network in Allentown, PA, seeks a Social Worker or RN Care Manager to coordinate discharge planning and provide psychosocial support across the care continuum.

You will collaborate with physicians, nurses, social workers and care teams to design and implement discharge plans, mitigate barriers to care, and assist patients and families with adjustment to illness and hospitalization.

Qualifications

• 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.

Responsibilities

• Develops a discharge plan that addresses the psycho-social needs to meet desired goals for the next step in the continuum of care for patients.
• Collaborates with the patient, family or other caregivers, and multidisciplinary team to design a discharge plan respective of the patient’s needs and goals.
• Works as a team with other members of care management, including RN care managers, assistants, coordinators, utilization management staff, and director.
• Facilitates communication among all treatment team members.
• Manages length of stay by identifying and mitigating issues and barriers to care and a successful discharge plan.
• Updates the care team, patient/family as to the status of the discharge plans.
• Re-evaluates and revises the discharge plan as additional information is acquired.
• Proactively considers options such as palliative care, homecare and other services to minimize readmissions.
• Issues applicable state/federal regulatory notices as applicable (IMM, MOON, BPCI).
• Monitors risk assessment using available tools and implements discharge interventions accordingly.
• Identifies patients with an unplanned readmission and completes root cause analysis.
• Coordinates utilization of patient and community resources to facilitate safe discharge and minimize readmission.
• Collaborates with Outpatient Care Managers to identify patients for handover and post discharge follow up.
• Provides supportive counseling and advocacy to assist patients and/or family with adjustment to illness and hospitalization.
• Facilitates decision making in complex cases and resolves issues with compassion.
• Acts as a resource to staff for regulatory issues regarding discharge-planning and psychosocial processes.
• Uses electronic systems to document care manager functions.

Skills

Discharge planning

Psycho-social assessment

Care coordination

Team collaboration

Communication

Critical thinking

Regulatory knowledge

Computer skills

Education

MSW or equivalent

PA RN license / NJ license (Warren Campus)

BSN within 3 years / MSN / Case Management Certification (preferred)

Job description

St. Luke’s University Health Network in Allentown, PA, seeks a Social Worker or RN Care Manager to coordinate discharge planning and provide psychosocial support across the care continuum.

You will collaborate with physicians, nurses, social workers and care teams to design and implement discharge plans, mitigate barriers to care, and assist patients and families with adjustment to illness and hospitalization.