Care Transitions Case Manager: Discharge Planning Pro

Duke Health; Raleigh (NC); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Relocation assistance

Commitment bonus

Job summary

Duke Raleigh Campus in Raleigh, NC is seeking a Case Manager to coordinate discharge planning and care transitions. You will assess patients, develop individualized plans, and collaborate with the care team to ensure safe, efficient transitions.

Minimum qualifications include a BSN or MSW, 3 years of relevant experience, and an ACM/CCM/ANCC certification within 3 years of hire; NC RN license for BSN-prepared candidates. This role offers professional growth and commitment bonuses.

Qualifications

• BSN or MSW required.
• Minimum of 3 years of relevant experience.
• Case Management Certification (ACM, CCM, or ANCC) required within 3 years of hire.
• For BSN-prepared candidates: Must hold a current RN license (or compact license) in North Carolina.

Responsibilities

• Assess all assigned patients for case management needs, including discharge planning, care transitions, advocacy, consultations, and patient/family education.
• Develop, implement, and evaluate individualized discharge plans ensuring timely and appropriate transitions of care.
• Coordinate services such as Home Health, Durable Medical Equipment (DME), transportation, outpatient follow-up, SNF placement, and Rehab referrals.
• Monitor daily census to ensure all patients are evaluated for case management needs.
• Maintain effective communication with the healthcare team regarding assessment findings, discharge needs, and provider orders.
• Provide education to patients, families, and care teams regarding benefits, reimbursement guidelines, and regulatory requirements.
• Collaborate with Utilization Management to support payer negotiations, reduce denials, and promote appropriate resource use.
• Maintain timely, accurate documentation of assessments, interventions, discharge arrangements, and all actions taken.
• Ensure compliance with federal, state, and local regulations, as well as organizational policies.
• Prepare reports and maintain records as required.
• Participate in Quality Assurance/Performance Improvement (QAPI) activities.
• Represent the department with professionalism while fostering positive working relationships across Duke Health and external partners.
• Provide weekend, holiday, or after-hours coverage as assigned based on entity needs.

Skills

Independent work

Problem-solving

Communication skills

Basic computer proficiency

Education

BSN or MSW

Tools

EMR software

Job description

Duke Raleigh Campus in Raleigh, NC is seeking a Case Manager to coordinate discharge planning and care transitions. You will assess patients, develop individualized plans, and collaborate with the care team to ensure safe, efficient transitions.

Minimum qualifications include a BSN or MSW, 3 years of relevant experience, and an ACM/CCM/ANCC certification within 3 years of hire; NC RN license for BSN-prepared candidates. This role offers professional growth and commitment bonuses.