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 health outcomes. This position acknowledges the impact of psychosocial factors on recovery and focuses on patient-centered assessments and coordination of post-acute care. By collaborating with interdisciplinary teams, patients, families, and community resources, the case manager plays a vital role in reducing hospital readmissions, lowering costs, and improving patient quality of life.

Essential Responsibilities:
- Conduct discharge screenings, evaluations, and develop discharge plans, especially for patients with complex needs.
- Continuously reassess and monitor discharge plans for changes in patient condition.
- 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 and continuity of care through interdisciplinary collaboration.
- Facilitate adoptions and follow-up calls in line with Transitions of Care policies.
- Assess patient needs remotely and apply appropriate interventions.
- Offer resources before and after admission to support effective discharge planning.
- Conduct chemical dependency and mental health assessments with referrals to treatment.
- Monitor readmission trends and conduct assessments.
- Provide Medicare Notification Letters.
- Assist with financial concerns by connecting patients to eligible programs and assistance.
- Perform assessments and referrals related to 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 either a healthcare emphasis including hospital field placement or prior experience in hospital or healthcare social services.
- Behavioral health experience is preferred.

Licensure/Certifications:
- Valid and active Social Work licensure required.

Work Shift: 1st Shift
Scheduled Weekly Hours: 40

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