Care Transitions & Discharge Specialist

Duke Health; Durham (NC); On-site; USD 41,000 - 62,000; Part time

Job summary

Duke Health, based in Durham, NC, seeks a Case Manager to coordinate care transitions and discharge planning across the continuum of care. You will work with interdisciplinary teams to ensure timely assessments, care transitions, and optimal patient outcomes.

The role emphasizes collaboration with patients, families, and community partners, with responsibilities including documentation, CMS compliance, and facilitating services such as Home Health and SNF referrals. RN or MSW preferred.

Qualifications

• BSN or MSW required.
• Minimum of 3 years of relevant case management experience.
• Case Management Certification within 3 years of hire.
• For BSN candidates: NC RN license or compact licensure.

Responsibilities

• Assess patients for case management needs, including discharge planning and care transitions.
• Develop, implement, and evaluate individualized discharge plans for timely transitions.
• Coordinate services such as Home Health, DME, transportation, SNF referrals, and rehab.
• Monitor daily census and ensure appropriate case management interventions.
• Maintain education for patients/families and collaborate with the care team.
• Ensure timely documentation and compliance with CMS and regulations.

Skills

Independent work

Problem solving

Communication skills

Basic computer proficiency

Education

BSN

MSW

Job description

Duke Health, based in Durham, NC, seeks a Case Manager to coordinate care transitions and discharge planning across the continuum of care. You will work with interdisciplinary teams to ensure timely assessments, care transitions, and optimal patient outcomes.

The role emphasizes collaboration with patients, families, and community partners, with responsibilities including documentation, CMS compliance, and facilitating services such as Home Health and SNF referrals. RN or MSW preferred.