Discharge & Care Coordination Social Worker

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

Job summary

St. Luke's University Health Network is seeking a Social Worker or RN Care Manager to coordinate complex discharge planning and provide psycho-social support across care settings. You will collaborate with clinicians, patients and families to design effective discharge plans, identify barriers and optimize outcomes.

The role emphasizes teamwork, documentation, and proactive care management to reduce readmissions while ensuring patient-centered care and regulatory compliance.

Qualifications

• MSW or equivalent from an accredited school of social work; NJ/PA licensure as applicable.
• RN with PA license; OB/other areas may have additional licensure requirements.
• Experience in discharge planning and psychosocial care preferred.

Responsibilities

• Develops a discharge plan addressing psychosocial needs and next-step goals.
• Collaborates with patient, family, and multidisciplinary team to design discharge plans.
• Works with RN care managers, coordinators and utilization staff to optimize care.
• Facilitates communication among treatment team and monitors readmission risks.
• Uses electronic systems to document care management activities.

Skills

Discharge planning

Care coordination

Psycho-social assessment

Team collaboration

Education

MSW or equivalent

RN license (PA)

Job description

St. Luke's University Health Network is seeking a Social Worker or RN Care Manager to coordinate complex discharge planning and provide psycho-social support across care settings. You will collaborate with clinicians, patients and families to design effective discharge plans, identify barriers and optimize outcomes.

The role emphasizes teamwork, documentation, and proactive care management to reduce readmissions while ensuring patient-centered care and regulatory compliance.