Job Summary: This role focuses on promoting optimal social and emotional functioning while enabling patients to effectively utilize healthcare and related services to achieve their best health outcomes. The case manager understands the impact of psychosocial factors on recovery and provides patient-centered assessments and coordination for post-acute care transitions. Working closely with an interdisciplinary team, patients, families, and community resources, this position aims to reduce readmissions, lower costs, and enhance patient quality of life.

Essential Responsibilities:
- Conduct discharge screening, evaluation, and develop discharge plans, especially for patients with complex needs.
- Reassess and monitor discharge plans for changes in patient condition.
- Advocate for patients alongside support persons and healthcare teams.
- Provide interventions and emotional support to families during healthcare decision-making.
- Manage crisis intervention, 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.
- Facilitate system integration, continuity of care, and interdisciplinary collaboration.
- Conduct follow-up calls in line with Transitions of Care policies.
- Assess patient needs remotely and apply appropriate interventions.
- Perform chemical dependency and mental health assessments with referrals.
- Evaluate readmission risks and trends.
- Provide Medicare notification letters.
- Assist with financial concerns by connecting patients to eligible programs.
- Conduct abuse assessments (adult, child, sexual, domestic violence) and make referrals.
- Assess Social Determinants of Health and assist patients in accessing government and social services.
- Provide information and support regarding advance directives.
- Participate in departmental and community meetings and initiatives as assigned.

Education and Experience Required:
- Master of Social Work (M.S.W.) from an accredited program with either a healthcare emphasis including hospital field placement or prior experience in hospital social services or healthcare settings.
- Behavioral health experience is preferred.

Licensure/Certifications:
- Valid and active Social Work licensure for the state of Indiana is required.

Work Shift: First shift, full-time, 40 hours per week.

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