As the Complex Care Nurse Manager provides evidence-based assessments, tools, information, and resources that enhance and improve the overall health and well-being of patients and their families in settings across the healthcare continuum. The complex care manager utilizes their knowledge of social determinants of health, care management, health disparities, and cross continuum care and collaborates with patients, caregivers, physicians, nurses, and other clinical staff/directors to coordinate, facilitate, and expedite patient care services across the continuum from pre-admission to discharge and continuing care. JOB RESPONSIBILITIES: + Rounds with the care team and collaborates with the team to identify patient/families with complex discharge needs. Determines appropriate referrals and facilitates appropriate discharge plans. + Works in conjunction with Utilization Review Nurse, Social Worker and Clinical Care Leader to ensure all appropriate interventions are made promoting a reasonable and timely discharge. + Completes discharge planning using high risk admission and discharge criteria set. Anticipates medical / psychosocial needs in high risk patients, e.g. chronic diagnoses, top ten DRGs, patients frequently accessing care, etc. + Collaborate with primary nurse and care team to ensure that patient and family are included in timely and efficient discharge planning. + Provides outreach, case finding/screening for high risk issues (social determinants of health) that may impact on patient's progress, participation in plan, discharge or ability to utilize/access resources. + Other duties as assigned. REQUIRED: + Graduate of an accredited professional nursing school + Current Massachusetts Nursing license + Bachelor’s degree required. + 5 years case management experience in an acute care setting with discharge planning, continuing care, care management, and utilization review. + Five years clinical nursing experience required + Demonstrated verbal, written skills + Computer skills required PREFERRED: + Master’s degree.