Job Description

Job Location Main Hospital Campus Headquarters - Madison, WV 25130 Position Type Full Time

The Case Manager (RN) serves as a care coordinator for patients and families throughout the hospitalization and transition of care process. This role focuses on discharge planning, psychosocial assessment, coordination of post-acute services, and patient advocacy to ensure safe, timely, and effective transitions across the continuum of care. The Case Manager collaborates with physicians, nursing staff, patients, families, and community resources to support patient-centered care and continuity of services.

Essential Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

• Coordinates patient care and discharge planning from admission through discharge to ensure continuity of care.
• Collaborates with physicians, nursing staff, and interdisciplinary team members to develop and implement individualized care and discharge plans.
• Meets directly with patients and families to assess medical, psychosocial, cultural, spiritual, and support needs.
• Coordinates referrals to appropriate community resources, social services, home health agencies, extended care facilities, rehabilitation services, and other support organizations.
• Facilitates discharge planning arrangements including long-term care placement, home health services, medical equipment, meal delivery, and in-home assistance programs.
• Participates in patient care conferences and interdisciplinary meetings as required.
• Encourages patient and family involvement in care planning and decision-making.
• Provides crisis intervention and support services as needed, including involvement in Emergency Department situations when appropriate.
• Maintains timely, accurate, and complete documentation of discharge planning and care coordination activities in the medical record.
• Communicates effectively with all departments to ensure patient needs are met and discharge barriers are addressed.
• Supports patient rights, dignity, and respectful care at all times.
• Maintains ongoing communication with referral sources and community partners.
• Participates in performance improvement and quality initiatives related to case management and patient outcomes.
• Assists with swing bed services and utilization review activities as assigned.
• Performs other duties as assigned.

Required Skills,

Qualifications, and Competencies

• Current, unrestricted Registered Nurse (RN) license required.
• Clinical nursing experience required; experience in case management, discharge planning, or care coordination preferred.
• Strong communication, collaboration, and organizational skills.
• Ability to assess and address psychosocial, cultural, and spiritual needs of patients and families.
• Working knowledge of community resources, post-acute care services, and discharge planning processes.
• Proficient in electronic health records and clinical documentation systems.
• Demonstrates professionalism, sound judgment, and a commitment to patient advocacy.

Supervisory Responsibilities

• None

Physical demands

• Primarily an office-based position with intermittent presence in patient care areas.
• Requires the ability to sit, stand, and walk for extended periods of time.
• Requires the ability to bend, stoop, reach, and move between offices and patient care areas as needed.
• May require occasional lifting of up to 15 pounds, such as files, supplies, or equipment.
• Requires visual acuity and the ability to communicate effectively in person and by telephone.
• May require availability for on-call or emergent situations as needed.

Travel required

• None

Education and experience

• Graduate of an accredited school of nursing required.
• Current, unrestricted Registered Nurse (RN) license in the state of employment required.
• Minimum of two years of clinical nursing experience required.
• Experience in discharge planning, case management, care coordination, or swing bed services preferred.
• Experience in an acute care or hospital setting preferred.
• CCM Certification preferred.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of all activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time.

Equal Employment Opportunity Policy Statement

Boone Memorial Hospital, Inc. provides equal employment opportunities to all personnel and applicants for employment and prohibits discrimination, harassment, prejudice, or behavior of any type based on race, color, religion, age, sex (including pregnancy), national origin, disability status, family medical history or genetic information, past or present military service, sexual orientation, gender identity or expression, family or parental status, political affiliation, or any other characteristic protected by federal, state or local laws.

Qualifications