**Description** Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve. Our Case Management team is seeking a **System-wide Complex Social Worker** to provide support to a network of 6 owned and 10 managed hospitals. This position is a 40 hour per week, full time exempt position that requires routine travel to support assigned facilities and teams, and will report to the Regional Director of Case Management. This role will collaborate with inpatient Case Management (CM) and Social Work (SW) teams to address patient-specific barriers, and serve as a liaison to managed hospitals for complex discharges, readmissions, and social needs. The role involves leading or supporting transition-of-care planning for high-utilizer, high-risk, or medically and socially complex patients. Additionally, the individual will provide on-site support or engage in virtual collaboration with hospitals requiring advanced case resolution, while integrating data and analytics into daily workflows to identify and monitor high-risk patients. Strengthening coordination with community-based partners and post-acute care agencies is also key for success in this role. Primary responsibilities include: 1. Patient Identification + Use system analytics dashboard to identify: + High-utilizer patients (3+ admissions in 6 months) + High-risk patients flagged by predictive analytics + Patients with discharge delays >3 days + Socially complex patients (homelessness, substance use disorder, guardianship, lack of POA) 2. Daily Coordination and Engagement + Participate in daily discharge planning huddles virtually or in person + Consult with inpatient CM/SW on new complex cases + Initiate contact with family, outside providers, payers, and community resources 3. Community Transition Support + Collaborate with outpatient or community-based partners (LTACH, SNFs, shelters, home health, FQHCs) + Ensure closed-loop handoffs with external care teams + Provide warm handoffs to managed care partners or community navigators 4. Complex Case Rounds (Weekly) + Facilitate systemwide case rounds for top 5% most complex patients + Identify process breakdowns and address gaps (housing, funding, placement) 5. Documentation & Metrics + Document interventions in EHR, care management platform, and complex care registry. Key metrics include: + Avoidable days + Readmissions + Discharge to home or community + Patient engagement touchpoints Other Responsibilities: 1. Assessments: Conduct thorough assessments of patients' mental, emotional, and social well-being to evaluate their needs and identify any barriers to their overall functioning. This includes assessing their support systems, coping mechanisms, mental health conditions, and psychosocial factors. 2. Patient-Centered Care Plans: Collaborate with providers, patients, their families, and the healthcare team on individualized care plans that align with patients' goals, preferences, and values. Resource Facilitation: Connect patients and their families with community resources, mental health services, support groups, and other relevant programs. This includes assisting with referrals for psychiatric evaluations, medication management, and coordinating care with other providers. 3. Progress Monitoring & Evaluation: Continuously monitor and evaluate the progress of patients' care plans to assess their response to interventions, measure outcomes, and make necessary adjustments. Collaborate with the healthcare team to ensure appropriate care progression, follow-up and continuity of care. 4. Advocacy: Advocate for patients' needs within the healthcare system and the community. This involves ensuring access to appropriate treatment, facilitating communication between patients and their healthcare team, and addressing any barriers or concerns that may impact the patient's well-being. 5. Active Listening: Engage in active listening to understand patients' experiences, concerns, and emotions. Provide a safe and non-judgmental space for patients to express themselves and offer empathy, validation, and support. 6. Respect for Individuality: Recognize and respect the unique values, beliefs, and cultural backgrounds of each patient. Tailor interventions and support to align with their individual needs and preferences, taking into account their cultural, social, and spiritual backgrounds. 7. Building Trust: Build trust-based relationships with patients and their families by demonstrating empathy, confidentiality, and professionalism. Foster open communication, collaboration, and a therapeutic alliance. 8. Risk Segmentation: Utilize risk segmentation strategies to identify patients who may require additional support or interventions based on their medical, psychological, and social risk factors. This helps prioritize resources and interventions for those who need them most. 9. Tasks or Interventions: Carry out specific tasks or interventions as delegated by the healthcare team. 10. Delegated Work: Collaborate with other members of the healthcare team to carry out delegated work, such as coordinating referrals, conducting follow-up assessments, and providing ongoing support to patients and their families. 11. Care Coordination: Coordinate care across different providers and settings to ensure seamless transitions and continuity of care. This may involve facilitating communication, sharing information, and advocating for the patient's needs. 12. Payer Communication: Communicate with payers, such as insurance companies or government agencies, to provide necessary information for authorization of services, reimbursement, or other documentation requirements. **Other Information** Other information: **Education Requirements:** ● Master's Degree in Social Work **Licensure/Certification Requirements:** ● None required **Professional Experience Requirements:** + Three (3) years of health care experience in Case Management strongly preferred **Knowledge/Skills/and Abilities Requirements:** • Knowledge of mental health conditions, diagnostic criteria, and evidence-based treatment modalities • Strong assessment and diagnostic skills • Excellent communication and interpersonal skills • Ability to collaborate effectively as part of an interdisciplinary team • Empathy, compassion, and cultural sensitivity • Strong organizational and time management skills • Ability to maintain confidentiality and adhere to ethical guidelines **Job Details** Legal Employer: NCHEALTH Entity: UNC REX Healthcare Organization Unit: Rex Case Management Services Work Type: Full Time Standard Hours Per Week: 40.00 Salary Range: $33.04 - $47.50 per hour (Hiring Range) Pay offers are determined by experience and internal equity Work Assignment Type: Onsite Work Schedule: Day Job Location of Job: US:NC:Raleigh Exempt From Overtime: Exempt: Yes This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position. Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity. Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.