Case Manager per diem for ARC

St. Luke’s University Health Network; Sellersville (Bucks County); On-site; USD 65,000 - 90,000; Full time

Job summary

St. Luke’s University Health Network in Bucks County, PA seeks a discharge planning professional to evaluate psycho-social needs of rehabilitation patients and coordinate comprehensive discharge plans.

The role requires collaboration with patients, families, and an interdisciplinary team to ensure safe, timely transitions and appropriate post-discharge services. Responsibilities include ongoing assessments, documentation, and securing authorizations while addressing barriers to care.

Qualifications

• MSW, RN (BSN preferred), or Masters in a related field may be considered based on experience.
• Preference for at least 2–5 years of clinical healthcare experience, preferably in rehab.
• St. Luke's University Health Network is an Equal Opportunity Employer.

Responsibilities

• Performs admission review identifying psycho-social barriers, interventions, and discharge needs.
• Completes ongoing assessments of discharge planning needs and mitigates barriers.
• Maintains clinical records of patient contact and interventions.
• Collaborates with patient, family, and interdisciplinary team to design discharge plans.
• Facilitates authorization, pre-certifications, and reviews related to discharge planning.

Skills

Interdisciplinary teamwork

Discharge planning

Documentation

Education

MSW

RN

Masters in related field

Job description

JOB DUTIES AND RESPONSIBILITIES

• Performs admission review on all rehabilitation patients that identifies psycho-social barriers, interventions to implement, and discharge planning needs to meet the desired goals for the next step in the continuum of care for the patient.
• Completes an ongoing assessments of discharge planning needs, identifies and mitigates barriers, and proactively facilitates changes to ensure a safe, timely and efficient discharge.
• Completes documentation
• Facilitates resolution of issues surrounding patient care in a compassionate, empathetic manner.
• Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis.
• Collaborates with the patient, family, or other caregivers, and interdisciplinary team to design a discharge plan respective of the patient’s needs and goals.
• Remain in contact with the patient/family at least three times per week to ensure the patient/family remains informed of the rehab process and discharge plans.
• Participates in daily “stand-up” meetings with the interdisciplinary team to briefly review patient progress and provide updates on information relevant to the patient’s plan of care.
• Participates in weekly Interdisciplinary Team Meetings for all patients which includes scheduling appropriate patients, completing documentation, and follow up with patients and families post meeting.
• Arranges for services prior to discharge to meet patient’s needs both at time of discharge, reduce readmission, and maintain a healthy long-term outlook.
• This includes but is not limited to community, state, and federal resources and DME acquisition.
• Provides appropriate assistance to complete medical paperwork.
• Provides education to patient and families around issues related to adaptation to the patient’s diagnosis, illness, treatment, discharge plan and/or life situation.
• Collaborates with outpatient Care Managers to identify patients for handover and post discharge follow-up.
• Acts as a resource to the staff for coverage issues, discharge options, community resources, and regulatory issues regarding discharge planning and psychosocial processes.
• Helps patients understand their rights regarding patient choice, medical treatment, advanced directives, and other related issues.
• Maintains clinical records of all patient contact, clinical reviews, and interventions according to hospital policy and other regulatory guidelines (i.e. Medicare, CARF, JCAHO, etc.).
• Documentation is completed in a progressional and timely manner and includes interventions, recommendations, and referrals.
• Facilitates authorizations, pre-certifications, concurrent reviews, and retro authorizations related to rehabilitation services and services pertinent to discharge planning.

PHYSICAL AND SENSORY REQUIREMENTS

• Sitting for up to 5 hours per day, 2 hours at a time.
• Standing for up to 1 hour per day, 1 hour at a time.
• Walking for up to 2 hours per day, 20 minutes at a time.
• Occasionally uses fingers to turn pages.
• Frequently uses hands to write, type, and hold charts.
• Rarely uses the hands or fingers for firm grasping or twisting/turning.
• Frequently uses upper extremities to lift and carry up to 10 pounds.
• Frequently stoops, occasionally squats, rarely reaches above shoulder level.
• Hearing as it relates to normal conversation in person or on telephone.
• Seeing as it relates to general vision, near vision, far vision, color vision, and peripheral vision.

EDUCATION

MSW, RN (BSN preferred), OR Masters in a related field of physical, occupational, or speech therapy may be considered based upon experience and knowledge of care management and discharge planning.

TRAINING AND EXPERIENCE

Preference is for at least two to five years of clinical experience in healthcare preferred, preferably in a rehabilitation hospital.

St. Luke's University Health Network is an Equal Opportunity Employer.

Founded in 1872, St. Luke’s University Health Network (SLUHN) is a fully integrated, regional, non-profit network of more than 23,000 employees providing services at 16 campuses and 350+ outpatient sites. With annual net revenue in excess of $4 billion, the Network’s service area includes 11 counties in two states: Lehigh, Northampton, Berks, Bucks, Carbon, Montgomery, Monroe, Schuylkill and Luzerne counties in Pennsylvania and Warren and Hunterdon counties in New Jersey. St. Luke’s hospitals operate the largest network of trauma centers in Pennsylvania, with the Bethlehem Campus being home to St. Luke’s Children’s Hospital. SLUHN is the only Lehigh Valley-based health care system to earn Medicare’s five-star ratings (the highest) for quality, efficiency and patient satisfaction. It is both a Leapfrog Group and Healthgrades Top Hospital and a Newsweek World’s Best Hospital. The Network’s flagship University Hospital has earned the 100 Top Major Teaching Hospital designation from Premier 13 times total and eleven years in a row, including in 2023 when it was identified as THE #4 TEACHING HOSPITAL IN THE COUNTRY. In 2021, St. Luke’s was identified as one of the 15 Top Health Systems nationally. St. Luke’s is the ONLY health care institution in the Lehigh Valley to be named a Top Workplace regionally repeating the exclusive honor for the third year in a row. Also, for the third straight year, St. Luke’s has been a Top Workplaces in the Philadelphia Region by the Philadelphia Inquirer, ranking 9th in the large employer category for 2025 and the only health care system in PA to receive this award. In 2025, St. Luke’s was recognized as a national Top Workplaces by USA Today, three years in a row, including the 3rd best health care system in the nation in 2023 and 2024. Lastly, in 2025, St. Luke’s was named a Top Workplace in New Jersey for the third year in a row.