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Complex Care Manager

Spotlight Preferred
Capital Health
Trenton, New Jersey, United States (on-site)
9 days ago



The Complex Care Manager manages the needs of patients with complex issues by proactively identifying patients who have multiple or complex medical and/or psychosocial or family barriers that could prolong the acute care hospital stay. Identifies the complicated social and financial factors and barriers to appropriate discharge and offers solutions and assures patients are referred to all available, appropriate social and financial resources post discharge in order to transition patient efficiently and achieve the desired outcomes.


  • Documents clinical record, comprehensive assessment of patient needs including barriers to timely discharge, clinical interventions, support and appropriate community resources according to policy and utilizing recognized format, such as, assessment, intervention, and plan. Documents clinical record appropriate interventions including assessment, plans, and referrals in the discharge planning process.
  • Documents in clinical record all referrals and clinical interventions related to abuse, neglect, domestic violence, alcohol and substance abuse, crisis intervention. Performs educational sessions for health care team related to abuse/neglect issues and reporting of same. Documents staff interventions in clinical record.
  • Updates the health care team on the progress of managing the social and financial barriers that delay appropriate transitions during multidisciplinary rounds, length of stay meetings, and medical record documentation.
  • Advocates for appropriate services for complex patients with payor and providers of post-acute care service, community service and other services in order to optimize patient outcome.
  • Leads complex care rounds and organizes and participates in family meetings with providers and the multidisciplinary team to coordinate transition of care.
  • Manages contract patients discharged from the hospital to ensure the post acute facility is working in the best interest of the patient and the hospital system.
  • Prepares all documents for guardianship proceedings including investigator reports, medical and psychiatric notes and documents required from the legal department.
  • Uses culturally competent skills to assess individual patient needs and refers to appropriate professional staff when necessary. Identifies barriers and plans for intervention to overcome or lessen barriers to achieve outcome as evidenced by treatment plan.


  • Master's degree in Social Work (MSW) or Registered Nurse (RN).
  • Three years of experience in a clinical setting performing clinical social work or case management.
  • Excellent communication, conflict management, organizational and planning skills.
  • Clinical training in a medical/clinical environment; knowledge of spreadsheet and word processing software, case management and patient information systems.
  • New Jersey license
  • AHA BLS - Healthcare Provider

Job Information

  • Job ID: 65153743
  • Workplace Type: On-Site
  • Location:
    Trenton, New Jersey, United States
  • Company Name For Job: Capital Health
  • Position Title: Complex Care Manager
  • Job Function: Case Management
  • Job Type: Full-Time
  • Job Duration: Indefinite
  • Min Education: BA/BS/Undergraduate
  • Min Experience: 3-5 Years
  • Required Travel: None

Capital Health is the region’s leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Comprised of two hospitals Capital Health is a dynamic accredited health care resource. A five-time Magnet®-recognized health system for nursing excellence, Capital Health serves as a Level II Regional Trauma Center, Comprehensive Stroke Center, Regional Perinatal Center (including a Level III NICU), and emergency Mental Health sc...

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