Case Manager Complex Guardianship

Job description

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together. About Duke Regional Hospital Pursue your passion for caring with Duke Regional Hospital in Durham, North Carolina. With 388 beds it is the second largest of Duke Health's four hospitals and offers a comprehensive range ofmedical, surgical, and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services. Duke Nursing Highlights: Duke University Health System is designated as a Magnet organization Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses. Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification. Duke University Health System has 6000 + registered nurses Quality of Life: Living in the Triangle! Relocation Assistance (based on eligibility) The Case Manager is responsible for managing an assigned caseload to ensure timely assessment, planning, implementation, and evaluation of discharge plans and care transitions across the continuum of care. This role supports optimal patient outcomes, effective resource utilization, and compliance with CMS and other regulatory agencies. The Case Manager collaborates closely with interdisciplinary teams, patients, families, and community partners to coordinate safe, efficient care transitions. Key Responsibilities Care Coordination & Discharge Planning Assess all assigned patients for case management needs, including discharge planning, care transitions, advocacy, consultations, and patient/family education. Develop, implement, and evaluate individualized discharge plans ensuring timely and appropriate transitions of care. Coordinate services such as Home Health, Durable Medical Equipment (DME), transportation, Substance Abuse Treatment, outpatient follow-up, Skilled Nursing Facility (SNF) placement, and Acute Rehab referrals. Monitor daily census to ensure all patients are evaluated for case management needs. Collaboration & Communication Maintain effective communication with the healthcare team regarding assessment findings, discharge needs, and provider orders. Provide education to patients, families, and care teams regarding benefits, reimbursement guidelines, and regulatory requirements. Collaborate with Utilization Management to support payer negotiations, reduce denials, and promote appropriate resource use. Documentation & Compliance Maintain timely, accurate documentation of assessments, interventions, discharge arrangements, and all actions taken. Ensure compliance with federal, state, and local regulations, as well as organizational policies. Prepare reports and maintain records as required. Quality & Professional Development Participate in Quality Assurance/Performance Improvement (QAPI) activities. Represent the department with professionalism while fostering positive working relationships across Duke Health and external partners. Provide weekend, holiday, or after-hours coverage as assigned based on entity needs. Knowledge, Skills & Abilities Ability to work independently in a self-directed role. Strong problem-solving skills and ability to manage complex situations. Excellent written and verbal communication skills. Basic computer proficiency. Minimum Qualifications Education BSN or MSW required Experience Minimum of 3 years of relevant experience License and Certification Case Management Certification (ACM, CCM, or ANCC) required within 3 years of hire For BSN-prepared candidates: Must hold a current RN license (or compact license) in the state of North Carolina. Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status. Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values. Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.