The CSW Care Management Lead is an advanced-level member of the Case Management team responsible for coordinating care for patients with significant medical and psychosocial needs, high risk for re-admission and/or prolonged hospitalizations. The Lead in collaboration with the Care Management staff will provide targeted support for the hospital's more complex cases and will lead system-level coordination through Complex Case Rounds (Quality Collaborative). The team will act as a bridge between inpatient care and other ambulatory or service-based teams to ensure continuity and prevent avoidable readmissions for the highest-risk patients.
Essential Job Function
- AssessmentConducts psychosocial assessments for identified Complex Case or High Utilizer patients and further screening assessments (eg SDOH, PHQ9, MMSE, SBIRT, etc) to address barriers affecting care.
- Provides follow up support for complex psychosocial cases identified by unit social workers, offering extended coordination and interventions for cases requiring intensive time and resource investment.
- Interdisciplinary Collaboration & LeadershipCo-Leads interdisciplinary Complex Case Rounds (Quality Collaborative) and provides specialized input into discharge planning and resource coordination.
- Individualized Discharge PlanningDevelops and implements comprehensive, patient-centered discharge plans to support patients with high-utilization patterns, behavioral health needs, substance use disorder, lack of social support or legal/financial barriers to care.
- Care Coordination & Transitions of CareCoordinates discharge and transportation needs to post-acute settings (eg Home, Long-Term Care, Assisted Living, Group Homes, Care Homes, Homeless Shelters, Substance and Behavioral Health facilities and out of state or out of country repatriations) for socially complex cases.
- Engages with known complex case patients in the ED and collaborates with ED providers, ED social workers and ED case managers to coordinate alternative care placement, wrap around services and community support that often require extended planning and resource navigation.
- Community CollaborationCollaborates and builds partnerships with a wide range of external agencies including but not limited to: Local Management Entities (LMEs), Group Homes, Nursing Facilities, Medicaid offices, Sheriff's Office, Dept of Health and Social Services, Homeless organizations, consulates, etcAdvocacyServes as a hospital-based advocate and liaison for vulnerable patient populations navigating complex systems.
- Ensures patients and providers understand the patient's right to self-determination and informed decision-making.
- Reports concerns of abuse, neglect and exploitation to the appropriate authorities in compliance with mandatory reporting laws and hospital policiesSupports patients and families in connection with resources and initiation of Guardianship services.
- Mentorship/Leading OthersMay provide clinical supervision and support to clinical social work interns.
- Participate in interview process, safety zone resolution, SME and resource for staff, coordination of coverage assignment, representation of department on strategic hospital initiatives, orientation and staff development, and on-call coverage.
Education
- Required: Master Degree from accredited school of Social Work
Experience
- Required: 5 years inpatient case management experience.Preferred: Experience in people management. ACM-SW or CCM certified with 3 years of inpatient case management experience
Licensure/Certification/Listing
- Required: LCSW in the state of NC, required BLS/CPR
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Cone Health
Feb 27, 2026