Inpatient Case Manager; Per Diem

Inpatient Case Manager (Per Diem) – North Country Healthcare

Location: Lancaster, NH

Salary: $47,000.00 – $74,000.00

Company: North Country Healthcare (NCH)

North Country Healthcare is a non‑profit affiliation of four medical facilities—Androscoggin Valley Hospital, North Country Home Health & Hospice Agency, Upper Connecticut Valley Hospital, and Weeks Medical Center—located in the White Mountains Region of New Hampshire. NCH operates community hospitals, specialty clinics, and home health and hospice services, employing hundreds of highly trained professionals who deliver integrated patient care. The organization is committed to the health and well‑being of the communities it serves and emphasizes high-reliability organization (HRO) principles in its management practices.

The Inpatient Medical Social Worker is an integral member of the inpatient care team, working closely with inpatient and outpatient team members as well as community partners. The role assists patients in overcoming barriers as they navigate the healthcare system and manage their health and wellness needs, supporting them by assessing needs, developing individualized care plans, and arranging appropriate post‑discharge services.

Collaboration with the interdisciplinary team ensures that plans of care are effectively executed to promote safe, timely, and appropriate discharges or transitions to the next level of care for Weeks Medical Center patients.

• High School Diploma
• NH Notary preferred
• Bachelor’s degree or working towards a bachelor’s degree in social work

• High School Diploma
• NH Notary preferred
• Bachelor’s degree or working towards a bachelor’s degree in social work

• Basic Life Support (BLS) for clinical staff, or Heartsaver CPR AED for nonclinical staff, with regular renewal and up to a three‑month grace period after expiration

• Computer literacy: knowledge of Microsoft Office (Word, Excel)
• Knowledge of medical terminology preferred
• Compassionate, able to relate to different clients with various needs
• Motivational, encouraging clients to follow care plans
• Strong verbal and written communication skills to explain case and care plans and maintain case records
• Critical thinking and problem‑solving skills to determine the best care plan after assessing clients and analyzing notes from healthcare and social workers
• Flexibility to change care plans when necessary to achieve optimal results
• Organization to manage multiple cases simultaneously

• Prior experience in human services preferred
• Case management experience in a medical setting or home care environment preferred

• Develop discharge plan on admission that will enable a smooth transition of care
• Meet with patients and families regularly for implementation of discharge plan
• Meet with other departments as needed for patient care and transition
• Work closely with hospitalists and interdepartmental team members to ensure proper steps toward discharge for each patient
• Document ongoing case management activities in the electronic health record
• Coordinate patient care conferences (family meetings) when necessary to ensure all disciplines work together for optimal outcomes
• Send and manage referrals for patients for discharge services including Home Health/Hospice, transportation, CAP, Meals on Wheels, CCM, and Community Health Workers (CHW)
• Assist patients with completion of Advanced Directives
• Serve as a point of contact, advocate, and resource for patient, family, care team, payers, and community resources
• Promote healthy behaviors in all populations and ensure navigation assistance with community resources
• Work closely with care management and staff from other facilities to coordinate transfers from outside facilities to Weeks and from Weeks to other facilities
• Act as an advocate and educational resource for patients and families
• Assess patients and families’ unmet needs and refer to other resources as appropriate
• Attend meetings as requested (e.g., readmission, IDT, staff meetings)
• Evaluate patient’s medical status to determine specific DME needs (e.g., mobility aids, respiratory equipment) as ordered by physicians

• Perform additional duties as assigned.
• Adhere to facility values, service excellence and standards of excellence.

• Entry level

• Full‑time

• Other

• Hospitals and Health Care