Case Manager, Bartram Skilled Nursing, PRN

Priority Dispatch Corp.; Jacksonville (FL); On-site; USD 52,000 - 70,000; Full time

Job summary

Brooks Rehabilitation at Bartram Crossing in Jacksonville, FL is seeking a Social Worker to interview patients and families, assess home environments, and coordinate discharge planning for rehab patients. The role emphasizes advocacy, resource navigation, and collaboration with the interdisciplinary team to ensure seamless transitions, quality care, and compliant documentation.

A BS/BA in social work is required; a Master’s degree is preferred, with at least two years of SNF case management

Qualifications

• Interviews patients and families to collect data on home environment, finances, health and social histories.
• Orients patients and families to rehab process and discharge planning options.
• Provides levels of case management, emotional support, and resource referrals.
• Demonstrates knowledge of reimbursement programs (Medicare/Medicaid) in discharge planning.
• Documents interventions accurately in patient records and follows up on plans.

Responsibilities

• Interviews patients/families to obtain data regarding home environment, family relationships, financial resources, health and social histories, in order to address the comprehensive needs of the patients/families.
• Orients patients/families to the rehab process and explores options regarding discharge planning, and the need for education and/or referral to community resources and support systems.
• Provides various levels of case management services when indicated, e.g., emotional support to patients/families which facilitates adaptation to the disability and post rehab planning.
• Relates a clear understanding of reimbursement/financial resources as applies to discharge planning, to include federal and state assistance programs such as Medicare and Medicaid.
• Documents interventions and developments in the patient's medical record. Records information in an accurate, timely, and concise manner.

Skills

Interview patients/families

Discharge planning

Advocacy for patient rights

Liaison with community resources

Documentation in medical record

Education

BS/BA in social work or related field

MSW or Masters preferred

Job description

About Brooks Rehabilitation: For over five decades, Brooks Rehabilitation has been at the forefront of physical rehabilitation care. The nonprofit, based in Florida, is recognized as the premier rehabilitation system and ranks among the top 20 nationally according to U.S. News & World Report. Brooks currently manages three inpatient hospitals in Florida and is set to expand its reach through a collaboration with Mayo Clinic, opening a new facility on Mayo's Phoenix campus in 2026. The organization's commitment to advancing rehabilitation science is evident in its focus on innovative research, education, and cutting-edge technology. Offering a comprehensive system of care, Brooks provides inpatient and outpatient services, skilled nursing, assisted living, and memory care and impacts lives beyond clinical settings through community programs designed to enhance the quality of life for individuals with physical disabilities.Location Overview: This position is located at our Bartram Crossing facility located on our beautiful 115-acre campus in Bartram Park, Fla. Brooks Bartram Crossing is one of only 19% of U.S. skilled nursing facilities recognized as a Best Nursing Home for 2019-20 by U.S. News & World Report and earned Best Nursing Homes status by achieving a rating of “High Performing,” the highest possible rating, for short-term rehabilitation. Bartram Crossing also received a CMS Five-Star Rating, The Joint Commission Gold Seal of Approval, and the Agency for Health Care Administration’s Silver Award. The American College of Health Care Administrators recognized Bartram Crossing as a top-performing Skilled Nursing Facility based on quality indicators, occupancy and three years of survey data. Bartram Crossing has also been rated with zero deficiencies on its state survey for two years in a row. If you are passionate about serving patients with a goal to provide the best care possible and an excellent patient experience, we invite you to join our award-winning, innovative organization.Qualifications:Interviews patients/families to obtain data regarding home environment, family relationships, financial resources, health and social histories, in order to address the comprehensive needs of the patients/families. Demonstrates knowledge of age-specific needs in assessing family systems.Orients patients/families to the rehab process and explores options regarding discharge planning, and the need for education and/or referral to community resources and support systems.Provides various levels of case management services when indicated, e.g., emotional support to patients/families which facilitates adaptation to the disability and post rehab planning.Relates a clear understanding of reimbursement/financial resources as applies to discharge planning, to include federal and state assistance programs such as Medicare and Medicaid.Documents interventions and developments in the patient's medical record. Records information in an accurate, timely, and concise manner.Provides follow-up, ongoing monitoring, and intervention as needed to assume implementation of discharge plans, patient/family adjustment.Assists with program evaluation and quality assurance activities through follow-up questionnaires and/or other data.Acts as a liaison between colleagues, other departments and community agencies. Develops and maintains liaisons with local, state, and federal resources.Acts as an advocate for patient rights, needs, and goals. Seeks patient involvement in planning to the greatest extent possible. Involves family/significant other when the patient cannot actively participate in goal setting.Obtains written consent upon release of medical records.Organizes individual workload and sets appropriate priorities based on patients' needs and departmental policies and standardsFosters positive and professional relationships with patients, families, physicians, staff, and department peers.Supports the interdisciplinary team process by formulating team conference reports and conferring with referral sources, patients, and families.Rotate weekends as needed to assure social service coverage in SNF.Qualifications: Minimum of BS/BA in social work or related field., Masters preferred. Experience in Skilled Nursing Facilities (SNF) desired. Two years minimum of case management experience.Compensation: Experience and education may be considered along with internal equity when job offers are extended.Hours: PRNLocation: 6209 Brooks Bartram Drive, Building 100, Jacksonville, FL 32258