St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The Registered Nurse or Social Worker Care Manager is responsible for coordinating the complex discharge planning needs of patients, as well as to provide supportive counseling, psycho-social assessment and interventions for designated patient populations across the continuum of care. Also works with the providers, registered nurse care managers, social workers, and multi-disciplinary care teams to facilitate the achievement of desired patient, quality, and financial outcomes.

JOB DUTIES AND RESPONSIBILITIES:

• Assesses the patient’s needs, goals, and barriers in relation to the patient’s clinical condition, psychosocial environment, and socioeconomic resources.

• Collaborates with the multidisciplinary team to plan, implement and evaluate the patient’s plan of care through rounding or other methods.

• Collaborates with the patient, family or other caregivers, and multidisciplinary team to design a discharge plan respective of the patient’s needs and goals. Re-evaluates and revises discharge plan of care as additional information is obtained or goals change.

• Proactively considers options such as palliative care, home care and other services that work to keep the patient as healthy as possible in the outpatient setting, minimizing the risk of re-admissions.

• Works as a team with other members of care management, including but not limited to: Social workers, assistants, coordinators, utilization management staff, and director.

• Facilitates communication among all treatment team members.

• Manages length of stay by proactively identifying and mitigating issues and barriers to care and a successful discharge plan.

• Monitors risk assessment using available tools and implements discharge interventions accordingly, minimizing risk of readmission.

• Identifies patients with an unplanned readmission and completes root cause analysis.

• Collaborates with Outpatient Care Managers to identify patients for handover and post discharge follow up.

PHYSICAL AND SENSORY REQUIREMENTS:

Sitting for one to two hours at a time, walk on all surfaces for up to five hours a day, and climb stairs. Must be capable of driving a car and have the ability to finger and handle objects frequently. Occasionally firmly grasp, twist, and turn objects with hands and fingers. May be required to lift, carry, push, and/or pull objects weighing up to 75 pounds. Occasionally stoops, bends, squats, kneels and reaches above shoulder level. Staff must have the ability to hear as it relates to normal conversations and high and low frequencies and to touch as related to telephone and computer keyboard.

EDUCATION:

MSW or equivalent from an accredited school of social work. Current NJ SW license if working at St. Luke’s Warren Campus. May hire per diem BSW’s currently in school within 6 months of completing MSW. If primary coverage area is OB, membership in the National Organization of Perinatal Social Workers is required.

OR:

Graduate of professional nursing program. Registered Nurse with current license to practice in the State of Pennsylvania or seeking Pennsylvania licensure through reciprocity. NJ RN licensure required for Warren Campus. Advanced degree preferred. BSN required or obtained within 3 years of hire, MSN and/or Case Management Certification preferred.

TRAINING AND EXPERIENCE:

Preference is for at least two years of experience as an RN or Social Worker in an acute hospital setting. Previous care management experience is preferred. Strong critical thinking skills. Ability to maintain collaborative and effective working relationships. Able to assert needs to patients, families, physicians, and other members of the interdisciplinary team while maintaining established rapport and relationships. Knowledge of medical terminology required. Ability to communicate both verbally and in written forms. Basic computer skills required.

LOCATIONS:

Campuses available : -Allentown Campus -Anderson Campus -Bethlehem Campus -Geisinger St. Luke’s Campus, Orwigsburg -Monroe Campus, Stroudsburg -Sacred Heart Campus, Allentown -Upper Bucks Campus, Quakertown -Warren Campus, Phillipsburg NJ

SHIFT DETAILS:

• Full time, 36 or 40 hours per week  

• Part time, less than 36 hours per week  

• Per Diem (if available), minimum of 2 shifts/month

• All positions (including per diem) must have the ability to complete 7 consecutive business days of initial orientation as well as required unit orientation.

• Holiday and weekend requirements per unit and company policies .

• Positions may be available on days and weekend program options.

Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!

St. Luke's University Health Network is an Equal Opportunity Employer. (http://www.slhn.org/EOE)