Job Description
Sierra Medical Center in El Paso seeks an RN Case Manager or Social Worker to coordinate patient-centered care across the continuum. In this full-time role, you will assess clinical and psychosocial needs, develop individualized care and discharge plans, and connect patients with hospital and community resources. You'll collaborate closely with an interdisciplinary team to support safe transitions, reduce readmissions, and improve outcomes. The position offers the opportunity to grow in a supportive, innovative hospital focused on advanced technology, quality, and compassionate, culturally sensitive care.
Responsibilities
- Assess patients' medical, psychosocial, and discharge needs across the care continuum
- Develop and coordinate individualized care and discharge plans with the care team
- Collaborate with physicians, nurses, social services, and community partners
- Educate patients and families on care plans, resources, and self-management
- Arrange post-acute services, referrals, and community resources
- Monitor progress, adjust plans, and address barriers to care and compliance
- Ensure documentation accuracy and compliance with hospital and regulatory standards
- Support quality, safety, and readmission reduction initiatives
- Advocate for patient-centered, culturally sensitive care
- Participate in interdisciplinary rounds and case conferences
Required Skills
- Patient assessment
- Care coordination
- Discharge planning
- Utilization review
- Electronic health records (EHR)
- Interdisciplinary collaboration
- Community resource navigation
- Case management documentation
- Regulatory compliance (CMS/Joint Commission)
- Patient and family education
