65,317 Case Manager jobs in the United States

• Coordinate care for clients in CT, MA, VT, or NH, partnering with therapists, counselors, and healthcare providers to create individualized recovery plans.
• Assess needs, remove barriers, and develop actionable service plans that support short- and long-term recovery.
• Connect clients to critical local resources-treatment programs, housing, healthcare, peer support, and community services.
• Maintain consistent contact via phone, video, and secure messaging to keep clients engaged and on track.
• Facilitate referrals and ensure smooth handoffs to external providers for a full continuum of care.
• Advocate for client needs, including employment support, transportation, and community engagement.
• Use AI-enhanced documentation tools and telehealth platforms to accurately track progress and deliver efficient care.
• Occasionally meet clients in person to connect them to vital local resources.

• Required: Prior experience in SUD case management or client care coordination.
• Familiarity with recovery systems and best practices in supporting individuals with substance use disorders.
• Personal recovery experience is highly valued-we welcome the insight and empathy that lived experience brings.
• Strong communication and relationship-building skills in a remote care environment.
• Comfort with technology, including AI-driven tools, telehealth platforms, and electronic health records.
• In-depth knowledge of recovery resources and community services in Connecticut, Massachusetts, Vermont, and New Hampshire.
• A client-centered, empowering approach to care.

• Remote, part-time role with flexible hours.
• Competitive pay: $26-$32 per hour.
• Work with cutting-edge tools in behavioral health, including AI-powered systems.
• Supportive, mission-driven team that values your professional skills and lived experience.
• Directly impact client outcomes while enjoying the autonomy of remote work.

• Must reside in Connecticut, Massachusetts, Vermont, or New Hampshire (applications from other states will not be considered)
• Prior experience in Substance Use Disorder (SUD) case management or client care coordination
• Strong knowledge of recovery principles, community resources, and support systems in CT, MA, VT, or NH
• Excellent communication and relationship-building skills, with the ability to engage clients remotely
• Comfort using technology, including telehealth platforms, AI-powered documentation tools, and electronic health records
• Ability to work independently while collaborating effectively with a multidisciplinary team
• Personal experience in recovery is strongly encouraged and valued
• High level of professionalism, empathy, and client-centered focus

Req#

GENERAL STATEMENT OF RESPONSIBILITIES:

This is a FLSA non-exempt position. Seeking an individual to join our collaborative team and lead child and family specific, wraparound teams in the High Fidelity Wraparound Model. The Case Manager-Intensive Care Coordinator will support youth and families through team facilitation, clinical engagement, assessment, service planning, linking to services, monitoring service delivery, crisis management, conflict resolution, collaboration with community partners and service providers, and group process management skills. The Case Manager-Intensive Care Coordinator will receive training in the High Fidelity Wraparound Model and will work in close collaboration with youth and caregivers to assure youth and family voice in developing plans to keep youth in their home and community or transition back into the community from out of home treatment placements.

MAJOR DUTIES:
The essential functions of this job are starred below (*) under "Major duties."
1. *Completes comprehensive strengths based child and family assessments.
2. *Conducting diagnostic assessments, including integration of observational data, in determining service eligibility and referral needs
3. *Completing program specific needs assessments and authorizations necessary for Medicaid or CSA reimbursement
4. *Assessing needs and planning services to include developing a comprehensive individualized services plan.
5. *Facilitate wrap around teams
6. *Enhancing community integration through increased opportunities for community access and involvement with natural supports
7. *Linking monitoring service delivery through contacts with individuals receiving services, service providers and periodic site and home visits to assess the quality of care and satisfaction of the individual.
8. Providing clinical review of services for identified CSA service recipients to assure quality of care & collaborate with case agency to review and follow up on funding.
9. *Reading all agency communication (i.e., Ten, Region Ten's Newsletter, e-mail, etc.)
10. *Providing individual and group counseling, as approved by supervisor, to meet licensure core competencies.
11. *Other duties as assigned by the supervisor in keeping with the general requirements of the position.

QUALIFICATIONS:

All candidates must hold an LPC or LCSW license, be registered with the Department of Health Professionals and actively seeking licensure, must register with the Department of Health Professionals within 6 months of hire, or be in a clinical master's program. At least one year of relevant work experience with child population. To ensure the safe and efficient operation of the program, a valid Virginia Driver's License plus an acceptable driving record as issued by the Division of Motor Vehicles are required. For client related use of a personal automobile, a certificate of valid personal automobile insurance must be provided.

EDUCATION:
• Master's in Counseling, Clinical Social Work or Family Therapy (required)
• OR enrolled in one of the above (required)

EXPERIENCE:
• Experience working with youth in a clinical or educational setting.

CERTIFICATION/LICENSE:
• LPC, LCSW or LMFT (preferred)
• Registered with the Department of Health Professionals and actively seeking licensure (preferred)
• Register with the Department of Health Professionals within 6months of hire (preferred)

KSAS

Skills in:
1. Interviewing and completing diagnostic assessments
2. Crisis counseling
3. Effective oral, written and interpersonal communication
4. Negotiating with consumers and service providers.
5. Observing, recording and reporting on an individual's functioning, utilizing available assessment tools
6. Identifying and documenting a consumer's needs for resources, services, and other supports.
7. Using information from assessments, evaluations, observation and interviews to develop service plans.
8. Identifying services within community and established service system to meet the individual's needs.
9. Promoting goal attainment
10. Identifying community resources and organizations and coordinating resources and activities.

Abilities to:

1. Be persistent and remain objective
2. Work as a team member, maintaining effective inter and intra-agency working relationships.
3. Demonstrate a positive regard for consumers and their families (e.g., treating consumers as individuals, allowing risk-taking, avoiding stereotyping, and respecting consumers' and families' privacy).
4. Work independently performing position duties under general supervision.
5. Communicate effectively, verbally, and in writing.
6. Establish and maintain ongoing supportive relationships.

Grade: 9

Position Location:
500 Old Lynchburg
Charlottesville, VA 22903

Schedule: Full Time Monday-Friday 8:30-5pm

Position :

Location : 500 OLD LYNCHBURG RD

Details : Job Description

1. Assessment and Planning:
   • Conduct thorough assessments of clients' needs, strengths, and goals.
   • Develop comprehensive care plans tailored to each client's unique situation.
   • Collaborate with clients and their support networks to set achievable objectives.
2. Resource Coordination:
   • Identify and connect clients with appropriate community resources, including medical services, housing assistance, counseling, and vocational training.
   • Assist clients in accessing financial assistance and benefits, such as Medicaid, Social Security, or other entitlement programs.
   • Facilitate referrals to specialists and service providers as needed.
3. Advocacy and Support:
   • Advocate on behalf of clients to ensure they receive quality care and services.
   • Offer emotional support and crisis intervention as required.
   • Assist clients in developing self-advocacy skills to navigate the healthcare and social services systems.
4. Monitoring and Documentation:
   • Regularly monitor clients' progress towards their goals and adjust care plans as necessary.
   • Maintain accurate and up-to-date client records, ensuring compliance with confidentiality and legal requirements.
   • Prepare and submit reports to supervisors and relevant agencies as needed.
5. Education and Empowerment:
   • Provide clients and their families with information and education about available services and resources.
   • Foster independence and self-sufficiency by teaching clients life skills and problem-solving techniques.
6. Collaboration and Communication:
   • Collaborate with interdisciplinary teams, including healthcare providers, social workers, therapists, and other professionals.
   • Communicate effectively with clients, families, and external agencies to ensure seamless service delivery.

• Bachelor's degree in social work, psychology, counseling, nursing, or a related field (Master's degree preferred).
• Relevant certification or licensure (e.g., Certified Case Manager, Licensed Clinical Social Worker).
• Previous experience in case management, social work, or a related field.
• Strong communication, interpersonal, and problem-solving skills.
• Knowledge of community resources and social services.
• Empathy, patience, and the ability to work with diverse populations.
• Proficiency in computer applications and record-keeping systems.

• Competitive salary and benefits package.
• Opportunities for professional growth and advancement.
• Access to ongoing training and development programs.
• Supportive and collaborative work environment.
• Meaningful work that makes a difference in patients' lives.

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

WellStar Kennestone Hospital has an opportunity for a Care Coordinator Complex (RN) - Case Manager

Full Time - Day Shift

Job Summary:

The RN Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's clinical, psychosocial and resource needs. In conjunction with the patient and physician, the Complex Care Coordinator assesses, coordinates, and implements a timely, safe patient discharge plan to the next appropriate level of care. Overall, this role draws on the strong clinical and social expertise of the Care Coordinator to integrate and coordinate the most challenging patients transitional care plans based on needs and resources available.

Specific functions within this role include:
Responsible for providing comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to include timely and appropriate planning to advance the discharge plan.
Carries appropriate caseload of select complex patients as specified by hospital criteria, providing all care coordination responsibilities in coordination with the patient care team.
Participates in the interdisciplinary team providing information about community-based service offerings (e.g.-indigent services, housing, social referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
Serves as a specialist on issues related to complex psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life.
Partners and serves as an expert resource to other Care Coordinators and interdisciplinary team members concerning complex social determinants of health issues, financial, legal, situational dynamics, and social needs.
Participates in precepting of new care coordinators (as needed) to teach and expose them to the most complex patient care needs and family dynamics. Mentor other care coordinators in case reviews and discussion of difficult situations, to include, but not limited to patient legal status, court regulations, financial options, suicidal ideation, grief and bereavement, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios.
May serve as facilitator of hospital team meetings to reduce the length of stay and resource consumption of complex patient population.
Supports leaders in negotiating agreements with community agencies and facilities.
May have other duties assigned as it relates to hospital complex patient population

Core Responsibilities and Essential Functions:

Assessment
- a.Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge. b.Partners with the PAS, financial counselor, and/ or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements. c.Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans. Complex Disposition Planning
- a.Implements discharge planning and provides resource information in a timely and efficient manner for complex patients. b.Identifies and documents barriers for timely disposition. c.Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge. d.Responds to referrals for patient assistance from RN physicians and the care team. e.Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge. f.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. g.Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum. h.Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning. i.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. j.Arranges and facilitates family meetings when needed. k.Allows for any cultural or religious beliefs in providing service and continuity of care.
- Documentation a.Initial psychosocial /functional assessment completed and documented in medical record. b.Ensure all records are up-to-date and documentation is understandable. c.Ensure timely and accurate documentation of progress notes and interactions with patient/family. d.Accounts for and indicates all services arranged/delivered in Electronic Health Record. e.Enter avoidable days, when applicable, in the Electronic Health Record. Professional Development and Initiative *a.Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. b.Supports departmental- based goals which contribute to the success of the organization. c.Participates in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes.
-
Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns
-
Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns
-
Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns

Required Minimum Education:

Bachelor's Degree in Social Work or a masters degree in Social Work from an accredited college or university. Required or
Bachelor's Degree in Nursing Required

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

• Reg Nurse - Board Cert or RN - Multi-state Compact
• Basic Life Support or BLS - Instructor
• Accredited Case Manager-Preferred or Certified Case Manager-Preferred

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environment in care coordination. Required and
Minimum 2 years in care coordination in the acute care setting. Required

Required Minimum Skills:

Excellent written and verbal communication skill.
Must possess maturity, self-confidence, objectivity, and positive attitude.
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment
Strong assessment, interview, organizational and problem-solving skills.
Knowledge regarding local, state and federal regulations required.
Knowledge of community and state-wide resources and programs.
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.

By applying, you consent to your information being transmitted by College Recruiter to the Employer, as data controller, through the Employer’s data processor SonicJobs.
See Wellstar Health System, Inc. Privacy Policy at financial-policy-and-privacy-info and SonicJobs Privacy Policy at us/privacy-policy and Terms of Use at us/terms-conditions

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

WellStar Kennestone Hospital has an opportunity for a Care Coordinator Complex (RN) - Case Manager

Full Time - Day Shift

Job Summary:

The RN Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's clinical, psychosocial and resource needs. In conjunction with the patient and physician, the Complex Care Coordinator assesses, coordinates, and implements a timely, safe patient discharge plan to the next appropriate level of care. Overall, this role draws on the strong clinical and social expertise of the Care Coordinator to integrate and coordinate the most challenging patients transitional care plans based on needs and resources available.

Specific functions within this role include:
Responsible for providing comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to include timely and appropriate planning to advance the discharge plan.
Carries appropriate caseload of select complex patients as specified by hospital criteria, providing all care coordination responsibilities in coordination with the patient care team.
Participates in the interdisciplinary team providing information about community-based service offerings (e.g.-indigent services, housing, social referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
Serves as a specialist on issues related to complex psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life.
Partners and serves as an expert resource to other Care Coordinators and interdisciplinary team members concerning complex social determinants of health issues, financial, legal, situational dynamics, and social needs.
Participates in precepting of new care coordinators (as needed) to teach and expose them to the most complex patient care needs and family dynamics. Mentor other care coordinators in case reviews and discussion of difficult situations, to include, but not limited to patient legal status, court regulations, financial options, suicidal ideation, grief and bereavement, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios.
May serve as facilitator of hospital team meetings to reduce the length of stay and resource consumption of complex patient population.
Supports leaders in negotiating agreements with community agencies and facilities.
May have other duties assigned as it relates to hospital complex patient population

Core Responsibilities and Essential Functions:

Assessment
- a.Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge. b.Partners with the PAS, financial counselor, and/ or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements. c.Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans. Complex Disposition Planning
- a.Implements discharge planning and provides resource information in a timely and efficient manner for complex patients. b.Identifies and documents barriers for timely disposition. c.Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge. d.Responds to referrals for patient assistance from RN physicians and the care team. e.Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge. f.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. g.Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum. h.Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning. i.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. j.Arranges and facilitates family meetings when needed. k.Allows for any cultural or religious beliefs in providing service and continuity of care.
- Documentation a.Initial psychosocial /functional assessment completed and documented in medical record. b.Ensure all records are up-to-date and documentation is understandable. c.Ensure timely and accurate documentation of progress notes and interactions with patient/family. d.Accounts for and indicates all services arranged/delivered in Electronic Health Record. e.Enter avoidable days, when applicable, in the Electronic Health Record. Professional Development and Initiative *a.Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. b.Supports departmental- based goals which contribute to the success of the organization. c.Participates in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes.
-
Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns
-
Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns
-
Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns

Required Minimum Education:

Bachelor's Degree in Social Work or a masters degree in Social Work from an accredited college or university. Required or
Bachelor's Degree in Nursing Required

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

• Reg Nurse - Board Cert or RN - Multi-state Compact
• Basic Life Support or BLS - Instructor
• Accredited Case Manager-Preferred or Certified Case Manager-Preferred

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environment in care coordination. Required and
Minimum 2 years in care coordination in the acute care setting. Required

Required Minimum Skills:

Excellent written and verbal communication skill.
Must possess maturity, self-confidence, objectivity, and positive attitude.
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment
Strong assessment, interview, organizational and problem-solving skills.
Knowledge regarding local, state and federal regulations required.
Knowledge of community and state-wide resources and programs.
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.

By applying, you consent to your information being transmitted by Veritone to the Employer, as data controller, through the Employer’s data processor SonicJobs.
See Wellstar Health System, Inc. Privacy Policy at and SonicJobs Privacy Policy at and Terms of Use at

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

WellStar Kennestone Hospital has an opportunity for a Care Coordinator Complex (RN) - Case Manager

Full Time - Day Shift

Job Summary:

The RN Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's clinical, psychosocial and resource needs. In conjunction with the patient and physician, the Complex Care Coordinator assesses, coordinates, and implements a timely, safe patient discharge plan to the next appropriate level of care. Overall, this role draws on the strong clinical and social expertise of the Care Coordinator to integrate and coordinate the most challenging patients transitional care plans based on needs and resources available.

Specific functions within this role include:
Responsible for providing comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to include timely and appropriate planning to advance the discharge plan.
Carries appropriate caseload of select complex patients as specified by hospital criteria, providing all care coordination responsibilities in coordination with the patient care team.
Participates in the interdisciplinary team providing information about community-based service offerings (e.g.-indigent services, housing, social referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
Serves as a specialist on issues related to complex psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life.
Partners and serves as an expert resource to other Care Coordinators and interdisciplinary team members concerning complex social determinants of health issues, financial, legal, situational dynamics, and social needs.
Participates in precepting of new care coordinators (as needed) to teach and expose them to the most complex patient care needs and family dynamics. Mentor other care coordinators in case reviews and discussion of difficult situations, to include, but not limited to patient legal status, court regulations, financial options, suicidal ideation, grief and bereavement, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios.
May serve as facilitator of hospital team meetings to reduce the length of stay and resource consumption of complex patient population.
Supports leaders in negotiating agreements with community agencies and facilities.
May have other duties assigned as it relates to hospital complex patient population

Core Responsibilities and Essential Functions:

Assessment
- a.Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge. b.Partners with the PAS, financial counselor, and/ or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements. c.Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans. Complex Disposition Planning
- a.Implements discharge planning and provides resource information in a timely and efficient manner for complex patients. b.Identifies and documents barriers for timely disposition. c.Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge. d.Responds to referrals for patient assistance from RN physicians and the care team. e.Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge. f.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. g.Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum. h.Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning. i.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. j.Arranges and facilitates family meetings when needed. k.Allows for any cultural or religious beliefs in providing service and continuity of care.
- Documentation a.Initial psychosocial /functional assessment completed and documented in medical record. b.Ensure all records are up-to-date and documentation is understandable. c.Ensure timely and accurate documentation of progress notes and interactions with patient/family. d.Accounts for and indicates all services arranged/delivered in Electronic Health Record. e.Enter avoidable days, when applicable, in the Electronic Health Record. Professional Development and Initiative *a.Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. b.Supports departmental- based goals which contribute to the success of the organization. c.Participates in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes.
-
Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns
-
Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns
-
Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns

Required Minimum Education:

Bachelor's Degree in Social Work or a masters degree in Social Work from an accredited college or university. Required or
Bachelor's Degree in Nursing Required

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

• Reg Nurse - Board Cert or RN - Multi-state Compact
• Basic Life Support or BLS - Instructor
• Accredited Case Manager-Preferred or Certified Case Manager-Preferred

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environment in care coordination. Required and
Minimum 2 years in care coordination in the acute care setting. Required

Required Minimum Skills:

Excellent written and verbal communication skill.
Must possess maturity, self-confidence, objectivity, and positive attitude.
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment
Strong assessment, interview, organizational and problem-solving skills.
Knowledge regarding local, state and federal regulations required.
Knowledge of community and state-wide resources and programs.
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.

By applying, you consent to your information being transmitted by Veritone to the Employer, as data controller, through the Employer’s data processor SonicJobs.
See Wellstar Health System, Inc. Privacy Policy at and SonicJobs Privacy Policy at and Terms of Use at

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Full Time - Day Shift

Job Summary:

The RN Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's clinical, psychosocial and resource needs. In conjunction with the patient and physician, the Complex Care Coordinator assesses, coordinates, and implements a timely, safe patient discharge plan to the next appropriate level of care. Overall, this role draws on the strong clinical and social expertise of the Care Coordinator to integrate and coordinate the most challenging patients transitional care plans based on needs and resources available.

Specific functions within this role include:
Responsible for providing comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to include timely and appropriate planning to advance the discharge plan.
Carries appropriate caseload of select complex patients as specified by hospital criteria, providing all care coordination responsibilities in coordination with the patient care team.
Participates in the interdisciplinary team providing information about community-based service offerings (e.g.-indigent services, housing, social referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics.
Serves as a specialist on issues related to complex psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life.
Partners and serves as an expert resource to other Care Coordinators and interdisciplinary team members concerning complex social determinants of health issues, financial, legal, situational dynamics, and social needs.
Participates in precepting of new care coordinators (as needed) to teach and expose them to the most complex patient care needs and family dynamics. Mentor other care coordinators in case reviews and discussion of difficult situations, to include, but not limited to patient legal status, court regulations, financial options, suicidal ideation, grief and bereavement, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios.
May serve as facilitator of hospital team meetings to reduce the length of stay and resource consumption of complex patient population.
Supports leaders in negotiating agreements with community agencies and facilities.
May have other duties assigned as it relates to hospital complex patient population

Core Responsibilities and Essential Functions:

Assessment
- a.Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge. b.Partners with the PAS, financial counselor, and/ or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements. c.Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans. Complex Disposition Planning
- a.Implements discharge planning and provides resource information in a timely and efficient manner for complex patients. b.Identifies and documents barriers for timely disposition. c.Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge. d.Responds to referrals for patient assistance from RN physicians and the care team. e.Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge. f.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. g.Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum. h.Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning. i.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. j.Arranges and facilitates family meetings when needed. k.Allows for any cultural or religious beliefs in providing service and continuity of care.
- Documentation a.Initial psychosocial /functional assessment completed and documented in medical record. b.Ensure all records are up-to-date and documentation is understandable. c.Ensure timely and accurate documentation of progress notes and interactions with patient/family. d.Accounts for and indicates all services arranged/delivered in Electronic Health Record. e.Enter avoidable days, when applicable, in the Electronic Health Record. Professional Development and Initiative a.Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. b.Supports departmental- based goals which contribute to the success of the organization. c.Participates in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes.
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Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns
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Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns
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Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns

Required Minimum Education:

Bachelor's Degree in Social Work or a masters degree in Social Work from an accredited college or university. Required or
Bachelor's Degree in Nursing Required

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

• Reg Nurse - Board Cert or RN - Multi-state Compact
• Basic Life Support or BLS - Instructor
• Accredited Case Manager-Preferred or Certified Case Manager-Preferred

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environment in care coordination. Required and
Minimum 2 years in care coordination in the acute care setting. Required

Required Minimum Skills:

Excellent written and verbal communication skill.
Must possess maturity, self-confidence, objectivity, and positive attitude.
Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment
Strong assessment, interview, organizational and problem-solving skills.
Knowledge regarding local, state and federal regulations required.
Knowledge of community and state-wide resources and programs.
Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care.

Join us and discover the support to do more meaningful work-and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.

by Jobble

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives. WellStar Kennestone Hospital has an opportunity for a Care Coordinator Complex (RN) - Case Manager Full Time - Day Shift Job Summary: The RN Complex Care Coordinator is responsible for assessing complex patient transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as an expert resource for complex patient and situations and serves as a consultant to the other care team members regarding patient's clinical, psychosocial and resource needs. In conjunction with the patient and physician, the Complex Care Coordinator assesses, coordinates, and implements a timely, safe patient discharge plan to the next appropriate level of care. Overall, this role draws on the strong clinical and social expertise of the Care Coordinator to integrate and coordinate the most challenging patients transitional care plans based on needs and resources available. Specific functions within this role include: Responsible for providing comprehensive clinical and psychosocial assessments for complex patients (high risk of readmission, high cost, long stay, and/or difficult to place) to include timely and appropriate planning to advance the discharge plan. Carries appropriate caseload of select complex patients as specified by hospital criteria, providing all care coordination responsibilities in coordination with the patient care team. Participates in the interdisciplinary team providing information about community-based service offerings (e.g.-indigent services, housing, social referrals and assistance, specialty care or post-acute placements, elder assistance, etc.) and offers guidance to patients/families to assist with multi-system factors that affect patient/family psychosocial dynamics. Serves as a specialist on issues related to complex psychosocial and discharge needs, end of life care planning, resource needs, etc. Will provide resource information necessary to aid patient/families in decision making up to and including support for end of life. Partners and serves as an expert resource to other Care Coordinators and interdisciplinary team members concerning complex social determinants of health issues, financial, legal, situational dynamics, and social needs. Participates in precepting of new care coordinators (as needed) to teach and expose them to the most complex patient care needs and family dynamics. Mentor other care coordinators in case reviews and discussion of difficult situations, to include, but not limited to patient legal status, court regulations, financial options, suicidal ideation, grief and bereavement, social determinants of health, cultural or language barriers, abuse cases (both children and adult), along with many other scenarios. May serve as facilitator of hospital team meetings to reduce the length of stay and resource consumption of complex patient population. Supports leaders in negotiating agreements with community agencies and facilities. May have other duties assigned as it relates to hospital complex patient population Core Responsibilities and Essential Functions: Assessment - a.Based on preliminary screening of patients, initiates assessment of patients psychosocial risk factors and availability of resources to assist upon discharge. b.Partners with the PAS, financial counselor, and/ or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence to those requirements. c.Collaborates with the patient and family, along with the physician(s) and other members of the care team to fully establish and support both the patients care progression and discharge plans. Complex Disposition Planning - a.Implements discharge planning and provides resource information in a timely and efficient manner for complex patients. b.Identifies and documents barriers for timely disposition. c.Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge. d.Responds to referrals for patient assistance from RN physicians and the care team. e.Participates in Interdisciplinary Rounds with the patients care team to confirm estimated date of discharge and make recommendations for best level of care transition at discharge. f.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. g.Provides financial needs assessment for patients requiring assistance for follow-up care throughout the continuum. h.Advocates and partners with the patient and family to empower them to make autonomous health care decisions keeping the patient and their wishes at the center of all discharge planning. i.Initiates/facilitates post-acute referrals through departmental processes for timely transition to the next level of care. j.Arranges and facilitates family meetings when needed. k.Allows for any cultural or religious beliefs in providing service and continuity of care. - Documentation a.Initial psychosocial /functional assessment completed and documented in medical record. b.Ensure all records are up-to-date and documentation is understandable. c.Ensure timely and accurate documentation of progress notes and interactions with patient/family. d.Accounts for and indicates all services arranged/delivered in Electronic Health Record. e.Enter avoidable days, when applicable, in the Electronic Health Record. Professional Development and Initiative *a.Completes all initial and ongoing professional competency assessment, required mandatory education, population specific education. b.Supports departmental- based goals which contribute to the success of the organization. c.Participates in the development of protocols, procedures and performance improvement as indicated to optimize patient outcomes. - Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns - Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns - Precepting/Mentoring a.Assist leadership with precepting new hires when needed. b.Mentoring new and less senior employees in addressing challenging situations in assisting patients/families through the continuum of care. c.Serves as a preceptor and/or mentor for student interns Required Minimum Education: Bachelor's Degree in Social Work or a masters degree in Social Work from an accredited college or university. Required or Bachelor's Degree in Nursing Required Required Minimum License(s) and Certification(s): All certifications are required upon hire unless otherwise stated. Reg Nurse - Board Cert or RN - Multi-state Compact Basic Life Support or BLS - Instructor Accredited Case Manager-Preferred or Certified Case Manager-Preferred Additional License(s) and Certification(s): Required Minimum Experience: Minimum 3 years of experience in healthcare in the acute care setting, related field, skilled care or community environment in care coordination. Required and Minimum 2 years in care coordination in the acute care setting. Required Required Minimum Skills: Excellent written and verbal communication skill. Must possess maturity, self-confidence, objectivity, and positive attitude. Self-directed with the ability to function well under stress, handle change, and function in a fast-paced environment Strong assessment, interview, organizational and problem-solving skills. Knowledge regarding local, state and federal regulations required. Knowledge of community and state-wide resources and programs. Ability to work collaboratively with physicians, members of the care team, and the patient/family to assist through the continuum of care. Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more. By applying, you consent to your information being transmitted by Monster to the Employer, as data controller, through the Employer’s data processor SonicJobs. See Wellstar Health System, Inc. Privacy Policy at and SonicJobs Privacy Policy at and Terms of Use at

• Medical coverage available with a Health Savings Account (HSA) with 50% employer match
• Prescription coverage
• Dental and vision plans
• Patient advocate and Medicare specialists available at no cost
• Dependent Care Flexible Savings Account
• Wellness incentive (up to $250)
• 403b with up to 9% employer give/match
• Free life insurance and AD&D
• Paid Time Off (PTO)
• 9 paid holidays (7 recognized holidays plus a floating and birthday holiday per year)
• Tuition reimbursement (if applicable)
• Employee Assistance Program (EAP)

1. Engagement/Developing Enduring Relationships
2. Assessment
3. Service Planning
4. Evaluation
5. Resource Expert
6. Convener/Facilitator

• Valid driver's license with acceptable driving record and proof of vehicle insurance.
• State Police, FBI, and Child Abuse Clearances; CPSL Mandated Reporter-Recognizing and Reporting Child Abuse training per state regulation.

• Physical Demands: Requires vision, speech, and hearing.
• Environmental Factors: Community, home, school, daily access to private insured vehicle during work hours.
• Working Hours: A non-traditional work schedule as defined by service needs.