Hospital Case Manager — Care Transitions Specialist

Duke Health; Durham (NC); On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Relocation assistance

Job summary

Duke Health in Durham, NC seeks a Case Manager to oversee discharge planning and care transitions across the continuum of care. You will collaborate with interdisciplinary teams, patients, families, and community partners to coordinate safe and efficient care transitions.

Responsibilities include assessing patient needs, developing discharge plans, coordinating Home Health, DME, transports, and SNF referrals, plus maintaining timely documentation and compliance with CMS and regulations.

Qualifications

• BSN or MSW required.
• Minimum of 3 years of relevant experience.
• Case Management Certification required within 3 years of hire; BSN-prepared candidates must hold an RN license in NC.

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, Substance Abuse Treatment, outpatient follow-up, SNF placement, and Acute Rehab referrals.
• Maintain timely, accurate documentation of assessments, interventions, discharge arrangements, and all actions taken.
• Participate in QAPI activities and collaborate with teams to ensure quality and compliance.

Skills

Independent work

Problem solving

Communication skills

Computer proficiency

Education

BSN or MSW

Job description

Duke Health in Durham, NC seeks a Case Manager to oversee discharge planning and care transitions across the continuum of care. You will collaborate with interdisciplinary teams, patients, families, and community partners to coordinate safe and efficient care transitions.

Responsibilities include assessing patient needs, developing discharge plans, coordinating Home Health, DME, transports, and SNF referrals, plus maintaining timely documentation and compliance with CMS and regulations.