Job Summary: The role of the case manager is to enhance social and emotional well-being while helping patients effectively navigate healthcare and related services to reach their best possible health outcomes. This position acknowledges the impact of psychosocial factors on recovery and focuses on patient-centered assessments and coordination of post-acute care to ensure smooth transitions from hospital settings.

Key Responsibilities:

• Conduct discharge screenings, evaluations, and develop discharge plans, especially for patients with complex needs.
• Continuously reassess discharge plans and monitor changes in patient conditions.
• Advocate for patients alongside their support networks and healthcare teams.
• Provide interventions and emotional support to families facing healthcare decisions.
• Manage crisis interventions, adjustment to illness, and bereavement support.
• Coordinate resources such as skilled nursing facilities, home care, hospice, infusion services, long-term acute care, and durable medical equipment.
• Ensure system integration, continuity of care, and interdisciplinary collaboration.
• Handle adoptions and follow-up calls related to transitions of care policies.
• Assess patient needs remotely and provide appropriate interventions.
• Offer resources before or after admission to support effective discharge planning.
• Conduct chemical dependency and mental health assessments with referrals to treatment.
• Perform readmission assessments and trend analysis.
• Provide Medicare notification letters and assist with financial concerns by connecting patients to eligible programs.
• Assess and refer cases involving abuse (adult, child, sexual, domestic violence).
• Evaluate social determinants of health and assist patients in accessing government and social service programs.
• Provide information and facilitate execution of advance directives.
• Participate in departmental, hospital, and community meetings and initiatives as assigned.

Education and Experience:

• Master of Social Work (M.S.W.) from an accredited program with a focus on healthcare or relevant field placement, or equivalent experience in hospital social services or healthcare settings.
• Behavioral health experience is preferred.

Licensure/Certifications:

• Valid and active Social Work licensure required.

Work Shift: 8:00am – 4:30pm

This position is based in a regional healthcare setting within the Midwest United States.