Social Worker Care Manager Lead

About the Role

The CSW Care Management Lead is an advanced-level member of the Case Management team responsible for coordinating care for patients with significant medical and psychosocial needs, high risk for re-admission, and/or prolonged hospitalizations. The Lead collaborates with Care Management staff to provide targeted support for the hospital's most complex cases and leads system-level coordination through Complex Case Rounds (Quality Collaborative). The team acts as a bridge between inpatient care and other ambulatory or service-based teams to ensure continuity and prevent avoidable readmissions for the highest-risk patients.

Responsibilities

• Conducts psychosocial assessments for identified Complex Case or High Utilizer patients and further screening assessments (e.g., SDOH, PHQ9, MMSE, SBIRT) to address barriers affecting care.
• Provides follow-up support for complex psychosocial cases identified by unit social workers, offering extended coordination and interventions for cases requiring intensive time and resource investment.
• Co-leads interdisciplinary Complex Case Rounds (Quality Collaborative) and provides specialized input into discharge planning and resource coordination.
• Develops and implements comprehensive, patient-centered discharge plans to support patients with high-utilization patterns, behavioral health needs, substance use disorder, lack of social support, or legal/financial barriers to care.
• Coordinates discharge and transportation needs to post-acute settings (Home, Long-Term Care, Assisted Living, Group Homes, Care Homes, Homeless Shelters, Substance and Behavioral Health facilities, and out-of-state or out-of-country repatriations) for socially complex cases.
• If part of the ED Inpatient Care Management Team: Engages with known complex case patients in the ED and collaborates with ED providers, ED social workers, and ED case managers to coordinate alternative care placement, wrap-around services, and community support that often require extended planning and resource navigation.
• Collaborates and builds partnerships with external agencies, including but not limited to: Local Management Entities (LMEs), Group Homes, Nursing Facilities, Medicaid offices, Sheriff’s Office, Department of Health and Social Services, homeless organizations, and consulates.
• Serves as a hospital-based advocate and liaison for vulnerable patient populations navigating complex systems.
• Ensures patients and providers understand the patient’s right to self-determination and informed decision-making.
• Reports concerns of abuse, neglect, and exploitation to the appropriate authorities in compliance with mandatory reporting laws and hospital policies.
• Supports patients and families in connection with resources and initiation of Guardianship services.
• Provides clinical supervision and support to clinical social work interns.
• Participates in the interview process, safety zone resolution, serves as a subject matter expert (SME) and resource for staff, coordinates coverage assignments, represents the department on strategic hospital initiatives, assists with orientation and staff development, and provides on-call coverage.

Requirements

• Master’s degree from an accredited school of Social Work.
• 5 years of inpatient case management experience.
• LCSW in the state of North Carolina.
• BLS/CPR certification.

Preferred Qualifications

• Experience in people management.
• ACM-SW or CCM certification with 3 years of inpatient case management experience.