Care Transitions & Case Management Coordinator

Cape-Fear-Valley-Medical-Center-; Fayetteville (NC); On-site; USD 60,000 - 72,000; Full time

Job summary

Cape Fear Valley Medical Center in Fayetteville, NC seeks a CAP Case Manager to assess, plan, coordinate, and follow up care for beneficiaries, linking with medical, social, and behavioral services to promote whole-person wellbeing.

The role emphasizes transitions, readmission reduction, and community resource connections. Requires MSW; CCM preferred; 1 year medical social work experience; strong communication and independence.

Qualifications

• MSW required; CCM preferred (certificate).
• 1 year of medical social work, case management, disease management transitions coordination, or care coordination.
• Fluent in English; able to read, write, and communicate effectively.

Responsibilities

• Provide case management and care coordination to assigned CAP caseload to maximize client-centered outcomes.
• Coordinate Money Follows the Person Transitions and Community Transitions to reduce acute length of stay and avoid readmissions.
• Perform comprehensive interdisciplinary needs assessments and formulate person-centered care plans.
• Conduct follow-up visits and support after discharge to reduce readmission risk.
• Provide referrals and linkage to medical, behavioral, social, and other programs; document through eCAP.

Skills

Excellent communication

Independent work

Case management

Interpersonal skills

Education

Master’s degree in Social Work (MSW)

Job description

Cape Fear Valley Medical Center in Fayetteville, NC seeks a CAP Case Manager to assess, plan, coordinate, and follow up care for beneficiaries, linking with medical, social, and behavioral services to promote whole-person wellbeing.

The role emphasizes transitions, readmission reduction, and community resource connections. Requires MSW; CCM preferred; 1 year medical social work experience; strong communication and independence.