Inpatient Care Manager: Discharge Planning & Support

St. Luke’s Health Network, Inc.; Bethlehem (Northampton County); On-site; USD 55,000 - 85,000; Full time

Job summary

St. Luke's Health Network, Inc. is seeking a Social Worker or Registered Nurse Care Manager to coordinate complex discharge planning and provide psycho-social assessment across the continuum of care. This role involves counseling, collaboration with the care team, and proactive planning to ensure safe transitions.

You will work with RN care managers, social workers, and providers to optimize patient outcomes, manage length of stay, and consider homecare or palliative options as appropriate.

Qualifications

• MSW or equivalent from an accredited school of social work.
• Current NJ SW license if working at St. Luke's Warren Campus; RN license PA/NJ/PA licensure requirements.
• BSN required or obtained within 3 years; MSN and/or Case Management Certification preferred.

Responsibilities

• Develops a discharge plan addressing psycho-social needs for the next step in care.
• Collaborates with patient, family and multidisciplinary team to design discharge plans.
• Works with care management team to coordinate services and maintain communication across teams.
• Monitors risk and readmission indicators; updates care team and patient/family on status.
• Explores options such as palliative care, homecare and outpatient services.

Skills

Discharge planning coordination

Psycho-social assessment

Interdisciplinary collaboration

Effective communication

Education

MSW or equivalent

RN license (PA/NJ)

BSN/MSN / Case Management Certification

Tools

Electronic health records

Job description

St. Luke's Health Network, Inc. is seeking a Social Worker or Registered Nurse Care Manager to coordinate complex discharge planning and provide psycho-social assessment across the continuum of care. This role involves counseling, collaboration with the care team, and proactive planning to ensure safe transitions.

You will work with RN care managers, social workers, and providers to optimize patient outcomes, manage length of stay, and consider homecare or palliative options as appropriate.