The Case Manager is responsible for directing and coordinating the delivery of health care services and collaborating with the multidisciplinary team to create a safe discharge plan. The Case Manager facilitates communication and coordination between the health care team members and involves the patient and family in decision-making. Activities include encouraging appropriate use of health care resources, improving quality of care, maintaining cost-effectiveness for each patient’s individualized plan of care, and safely transitioning to the next most appropriate site of care.

Completes case management intake assessments within 72 business hours of admission as required to obtain social functioning information and identify resources available for coordination of care and discharge planning.

• Assists in providing information to family regarding possible community resources to support patients’ continued needs.

• Advocate for the patient during hospitalization, from admission to post-discharge.

• Collaborates with the physicians and other multidisciplinary team members to facilitate care.

• Monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient-focused, high quality, efficient, and cost-effective throughout the continuum.

• Facilitates necessary referrals for imaging, specialty appointments, and procedures for comprehensive care while inpatient.

• Facilitates transfer to other facilities when appropriate and necessary.

• Completes and submits prior authorizations.

• Schedules transportation.

• Communicates with patient/family and multidisciplinary team throughout the discharge planning process, including information obtained from initial and ongoing case management assessments, planning, implementation, interdisciplinary collaboration, progress, and family education/training.

• Coordinates and facilitates Family Care Conferences.

• Proactively identifies barriers to discharge and works on resolution.

• Collaborates/communicates with external case managers, including CPS, to identify and utilize available resources for post-discharge needs.

• Coordinates discharge referrals – DME, home health, hospice, outpatient follow-up appointments, and other recommendations by the treatment team.

• Provide counseling services under the supervision of LCSW.

• Documents in the medical record per department standards.

• Actively participates in clinical performance and process improvement activities.

• Promotes individual professional growth and development by meeting mandatory/continuing education requirements.

• Supports department-based goals which contribute to the success of the organization.

• Exhibits a positive professional demeanor to patients, and family/support persons, offering constructive communication, cooperation, and assistance to ensure a satisfactory patient stay of treatment.

• Respectful of other points of view and builds positive relationships with co-workers.

• Performs other duties as assigned.

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Job Requirements


• Experience in hospital-based nursing or social work.

• Prefer experience in pediatric, complex medical, rehabilitation, and/or behavioral case management.

• Current working knowledge of discharge planning, case management, performance improvement, disease or population management, and managed care reimbursement.

• Excellent interpersonal communication skills.

• Strong organizational and time management skills, as evidenced by the capacity to prioritize multiple tasks and role components.

• Ability to work independently and exercise sound judgment in interactions with physicians, payors, patients, and their families.

• Effective oral and written communication skills

• Proficient in computer skills of the entire Microsoft 365 (Excel, Outlook, SharePoint, Word, and Teams).

• Demonstrates commitment to the Partners-in-Caring process.

Education Required

  • Graduate of an accredited school of professional nursing required; Bachelor of Nursing preferred, or graduate of an accredited Master of Social Work program.

Additional Information


• Must be license eligible to practice as a Vocational Nurse or Registered Nurse in the state of Texas; or

• Must be license eligible to practice as a Master Social Worker (MSW) in the state of Texas