Job Summary: Identifies and facilitates appropriate non-acute Health Services for high-risk utilizers of Emergency Department Services. The Registered Nurse or Social Worker will address social determinants that may lead to subsequent hospitalization. Provides psychosocial assessments, plans, and implements various counseling, conducts, and coordinates discharge planning for consulted patients in the Emergency Department or as needed. Will also act as a resource to the Emergency Department staff to help with discharge planning and offer resources to patients and families as needed. These include Primary Care, Home Health, Palliative, Hospice, Assisted Living facilities, Skilled Nursing facilities and other post-acute community services Identifies recent patients discharged from the hospital and initiates clarification of reason/cause for Emergency Department visits. Focuses on the reduction of 30-day re-admissions. Utilizes multidisciplinary conferences as appropriate. Proactively collaborates with community agencies. Works collaboratively with other members of the Case Management and Emergency Department team for discharge planning evaluation and assessment on patients being admitted from the Emergency Department. Victims of domestic violence, child and adult neglect and abuse, and other DSS issues shall be the Case Manager's responsibility. Works with in –house patient population to assist Case Management staff as needed. Print 2nd IMM notification for the next day for in-house SW team and deliver IMM’s to patient rooms if time permits. Covers in-house patients for SW needs when routine SW staff is not available until end of shift. Assist with Psychiatric and Geri-Psychiatric placement from the Emergency Department. Monitor Birthplace and Pediatric needs for resources and DSS reports. Other duties as assigned. Qualifications: RN - Associates degree in Nursing from a recognized college or university required; advanced degree preferred BSN/MSN. Certification in Case Management preferred. Two+ years nursing experience. Experience in case management, home health, quality and/or utilization management, community or hospital setting preferred. Thorough knowledge of general nursing/social work principles, methods, techniques, community resources, discharge planning processes, and State/Federal laws as they relate to Case Managers role. Exemplary verbal and written communication, critical thinking, interpersonal/group/leadership negotiation skills, and detail-oriented focus. Ability to communicate well with patients, family, staff, providers, service lines, and community resources to promote positive outcomes. Proficient in computer skills and MS Office software. BLS preferred for hire but required completion within 3 months of hire date. Social Worker - Bachelor's or Master's degree in Social Work or related field from a recognized college or university required. At least 1-year social work experience required. Experience in case management, home health, quality and/or utilization management, community or hospital setting preferred. Thorough knowledge of general nursing/social work principles, methods, techniques, community resources, discharge planning processes, and State/Federal laws as they relate to Case Managers role. Exemplary verbal and written communication, critical thinking, interpersonal/group/leadership negotiation skills, and detail-oriented focus. Ability to communicate well with patients, family, staff, providers, service lines, and community resources to promote positive outcomes. Proficient in computer skills and MS Office software. BLS preferred for hire but required completion within 3 months of hire date. EOE AA M/F/Vet/Disability