Black Country Integrated Care Board

Complex Clinical Case Manager (Discharge to Assess)

The closing date is 06 November 2025

Job summary

Are you a passionate and experienced Band 7 Nurse seeking a new challenge? Are you committed to ensuring our patients receive exceptional care and support in the community? If so, we would like to invite you to join our Black Country Wolverhampton team, where youll play a pivotal role in the Discharge to Assess pathway within the All-Age Continuing Care service.

You will work alongside a multidisciplinary team of skilled health and social care practitioners to support seamless patient flow across acute and community settings ensuring patients receive the right care, at the right time, in the right place and prevent unnecessary hospital stays and readmissions.

We invite applications from registered nurses interested in contributing to a dynamic, multi-disciplinary team and supporting patients as they transition from hospital to home. By joining our team, you will play a vital role in enhancing patient outcomes and making a positive impact within our community.

Main duties of the job

Key Responsibilities:

Provide Continuing Healthcare expertise as part of the Discharge to Assess pathway.
Support triage and care navigation, helping patients transition safely and efficiently from hospital to community or home-based care.
Coordinate high-quality patient care, working closely with colleagues across health and social care.
Participate in stakeholder engagement, developing and maintaining good collaborative working relationships
Undertake healthcare assessments and develop robust care and support plans in collaboration with other healthcare professionals.
Offer clinical guidance to ensure best practices and optimal patient outcomes.
Engage in ongoing professional development and embrace learning opportunities.

Requirements:

Registered Nurse with a valid NMC registration.
Experience in a similar role, preferably within integrated or community-based care settings.
Ability to work a flexible 7-day rota, ensuring comprehensive and responsive support for patients and colleagues.
Demonstrated leadership and management skills, with a commitment to high standards of care.
Excellent communication and interpersonal abilities, with a collaborative approach to teamworking.
Dedication to delivering high-quality care and improving patient experience and outcomes.

About us

The Black Country Integrated Care Board (ICB) is a statutory NHS organisation responsible for developing a plan for meeting the health needs of 1.26 million people in the Black Country. We manage the NHS budget for Dudley, Sandwell, Walsall and Wolverhampton and are responsible for planning and buying Primary Medical Services (GPs), dental, optometry and pharmacy services.

We are part of the Black Country Integrated Care System (ICS), known as Healthier Futures, which is a partnership of organisations working together to bring health and social care services closer together for the good of our communities.

The ICB has five core values that underpin the way we work and help to guide our actions and the decisions we make for local people and communities. These are compassion, inclusivity, integrity, fairness and trust.

Our organisation is committed to creating the best place to work and believe in promoting and enhancing equality, diversity and inclusion. We encourage applications from all areas of the community who meet the criteria for the role, regardless of age, gender, disability, race, religion or sexual orientation.

We are also a bronze award holder under the Defence Employer Recognition Scheme (ERS) which recognises our commitment and support from UK employers for defence personnel.

Note: the ICB is unable to provide sponsorship to enable an individual to have the right to work in the UK, due to the size of the organisation.

Date posted

23 October 2025

Pay scheme

Agenda for change

Band

Band 7

Salary

£47,810 to £54,710 a year

Contract

Permanent

Working pattern

Full-time, Flexible working

Reference number

D9118-25-0013

Job locations

Wolverhampton Civic Centre

St Peter's Square

Wolverhampton

WV1 1SH

Job description

Job responsibilities

The post holder will be required to provide a high-quality resource of professional advice, guidance and expertise to members of the Individual Care Team, ICB and wider health and social care economy
Autonomously manage a case load of individuals with highly complex health needs providing significant clinical guidance to providers.
Ensure that all assessments are holistic in nature and utilise The National Framework for NHS Continuing Health Care.
To have an expert level of knowledge regards The National Framework and its application in practice. To be able to impart this knowledge to a variety of audiences.
To provide complex and sensitive information to patients, relatives/ representatives and often work in potentially hostile environments; relaying difficult decisions regarding care provision and managing patient and family expectations.
Provide continuity of care throughout the period of care and support. This will encompass close working with health and social care professionals and care providers.
Attend all meetings related the patient which may impact on the care provision and costs to meet identified needs
Liaise with multiple professionals involved in the patients care to ensure that a comprehensive understanding of all identified needs is available. Ensuring that each patient has a care plan that addresses all their identified needs and can be used to assist assessors when completing CHC assessments/reviews.
Present comprehensive written reports to ICB Eligibility Panel following any reviews completed once patients are in receipt of agreed care provision that identify a change in the level of care required. This includes being able to demonstrate improvements that may result in a reduction of care provided or a change the patients eligibility for NHS CHC.
To be responsible for negotiating care package costs and the monitoring of packages of fully funded care which are in excess of £1000 per week. To be responsible for ensuring these care packages are reviewed to an agreed time scale, identified by the Head of Service and that these are recorded on the ICB database.
Identify and process any safeguarding and quality of care issues and take appropriate action to ensure that peoples welfare is protected and that the quality and standard of services provided are at a level that is in line with ICB required standards. Close liaison with the ICB Quality Team is necessary to ensure ICB funded individuals are in receipt of high quality, safe care.
Ensure Mental Capacity Act is considered and ensure relevant processes are followed eg. Best Interests, DOLs
Develop and maintain effective working relationships with clinicians, general practitioners and providers in order to ensure continuity of care and address patient needs.
Provide a high-quality resource of professional advice, guidance and expertise to the ICB and partner agencies in addressing the needs of individuals with complex health needs.
Liaising with a variety of providers and arranging assessment of patients in order that the most appropriate placement/provider is identified.
Provide information and support to the senior managers when considering the most appropriate provider to address a patients identified needs and to act autonomously when required to agree care packages in excess of the usual ICB cost.
To maintain a formal record of all cases and ensure that all relevant clinical information is available and updated regularly, both electronically and in patient files.
Support the Head of CHC in working with partner agencies and other stakeholders in developing the local market for services to ensure that it reflects the requirements of individuals and is able to meet current and future needs
To call and chair multi-disciplinary meetings, including case conferences and discharge meetings to ensure continuity of care across agencies; thus improving patient and family experience.
Deputise for the Lead Nurse as required
Provide data in order that the ICB can continuously monitor care delivery and identify how performance of providers can be improved. Working closely with colleagues in the ICB Quality Team to assure the quality of care received by NHS funded individuals.
To have budgetary monitoring responsibilities and to ensure that the Head of Service is informed of any identified budget pressures or financial risks that may impact on the overall service budget. The post holder will need to demonstrate both quality of care and value for money in all placements.
To develop policies and procedures, as requested, which will support the overall delivery of NHS Funded Care within the ICB.
To contribute to and deliver training on CHC and FNC to a variety of audiences particularly in health and social care.
To provide professional support and mentoring to the nurse assessors within the team and provide additional support and training as required by the Lead Nurse.
To work within the NMC Code/Professional Code** and to meet requirements for revalidation.
To undertake and comply with all mandatory training.

Job description

Job responsibilities

The post holder will be required to provide a high-quality resource of professional advice, guidance and expertise to members of the Individual Care Team, ICB and wider health and social care economy
Autonomously manage a case load of individuals with highly complex health needs providing significant clinical guidance to providers.
Ensure that all assessments are holistic in nature and utilise The National Framework for NHS Continuing Health Care.
To have an expert level of knowledge regards The National Framework and its application in practice. To be able to impart this knowledge to a variety of audiences.
To provide complex and sensitive information to patients, relatives/ representatives and often work in potentially hostile environments; relaying difficult decisions regarding care provision and managing patient and family expectations.
Provide continuity of care throughout the period of care and support. This will encompass close working with health and social care professionals and care providers.
Attend all meetings related the patient which may impact on the care provision and costs to meet identified needs
Liaise with multiple professionals involved in the patients care to ensure that a comprehensive understanding of all identified needs is available. Ensuring that each patient has a care plan that addresses all their identified needs and can be used to assist assessors when completing CHC assessments/reviews.
Present comprehensive written reports to ICB Eligibility Panel following any reviews completed once patients are in receipt of agreed care provision that identify a change in the level of care required. This includes being able to demonstrate improvements that may result in a reduction of care provided or a change the patients eligibility for NHS CHC.
To be responsible for negotiating care package costs and the monitoring of packages of fully funded care which are in excess of £1000 per week. To be responsible for ensuring these care packages are reviewed to an agreed time scale, identified by the Head of Service and that these are recorded on the ICB database.
Identify and process any safeguarding and quality of care issues and take appropriate action to ensure that peoples welfare is protected and that the quality and standard of services provided are at a level that is in line with ICB required standards. Close liaison with the ICB Quality Team is necessary to ensure ICB funded individuals are in receipt of high quality, safe care.
Ensure Mental Capacity Act is considered and ensure relevant processes are followed eg. Best Interests, DOLs
Develop and maintain effective working relationships with clinicians, general practitioners and providers in order to ensure continuity of care and address patient needs.
Provide a high-quality resource of professional advice, guidance and expertise to the ICB and partner agencies in addressing the needs of individuals with complex health needs.
Liaising with a variety of providers and arranging assessment of patients in order that the most appropriate placement/provider is identified.
Provide information and support to the senior managers when considering the most appropriate provider to address a patients identified needs and to act autonomously when required to agree care packages in excess of the usual ICB cost.
To maintain a formal record of all cases and ensure that all relevant clinical information is available and updated regularly, both electronically and in patient files.
Support the Head of CHC in working with partner agencies and other stakeholders in developing the local market for services to ensure that it reflects the requirements of individuals and is able to meet current and future needs
To call and chair multi-disciplinary meetings, including case conferences and discharge meetings to ensure continuity of care across agencies; thus improving patient and family experience.
Deputise for the Lead Nurse as required
Provide data in order that the ICB can continuously monitor care delivery and identify how performance of providers can be improved. Working closely with colleagues in the ICB Quality Team to assure the quality of care received by NHS funded individuals.
To have budgetary monitoring responsibilities and to ensure that the Head of Service is informed of any identified budget pressures or financial risks that may impact on the overall service budget. The post holder will need to demonstrate both quality of care and value for money in all placements.
To develop policies and procedures, as requested, which will support the overall delivery of NHS Funded Care within the ICB.
To contribute to and deliver training on CHC and FNC to a variety of audiences particularly in health and social care.
To provide professional support and mentoring to the nurse assessors within the team and provide additional support and training as required by the Lead Nurse.
To work within the NMC Code/Professional Code** and to meet requirements for revalidation.
To undertake and comply with all mandatory training.

Person Specification

Experience

Essential

Significant experience gained over a number of years in a complex, multi-disciplinary environment
Extensive experience of case management with service users who have complex health needs
A clear knowledge and understanding of The National Framework for NHS Continuing Health Care and its application in practice
An understanding of the Mental Capacity Act 2005 and its application
An understanding of commissioning for complex health needs in the context of NHS Continuing Healthcare
Experience of monitoring a budget and understanding of financial systems and processes

Personal Qualities

Essential

Self-motivated and enthusiastic
Adaptability, flexibility to work and ability to cope with uncertainty and change
Works well with others, is positive and helpful, listens, involves, respects and learns from the contribution of others
Consistently looks to improve what they do, look for successful tried and tested ways of working, and also seeks out innovation
Actively develops themselves and supports others to do the same
Understanding of and commitment to equality of opportunity and good working relationships
Professional, calm and efficient manner

Skills and Knowledge

Essential

High level of working knowledge of the relevant legislation and theories underpinning the provision of services to the relevant client group
Demonstrable experience and knowledge of current key policies and priorities within the NHS, especially within Clinical commissioning Groups
A clear knowledge and understanding of service provision available locally, regionally and nationally for the client group
Understanding of relevant current NHS and social care market mechanisms
Good working knowledge of adult safeguarding
Awareness of Data Protection and confidentiality issues
Working knowledge of Microsoft Office with standard keyboard skills
Effective interpersonal and negotiation skills enabling effective communication with clients, other professionals, colleagues, partner agencies, providers and carers.
Excellent written and verbal communication including providing and receiving complex, sensitive or contentious information
Excellent time management skills
Ability to prioritise and to work effectively on own initiative
Ability to work in hostile environments and deal with conflict on a regular basis
Understanding of the commissioning/ procurement process for adults continuing health care packages

Qualifications

Essential

Relevant degree/professional qualification in Nursing*** (local areas may differ/could be Social Work))
Evidence of continuous professional development
Educated to degree level or equivalent level of experience of working at a senior level in a specialist area.

Person Specification

Experience

Essential

Significant experience gained over a number of years in a complex, multi-disciplinary environment
Extensive experience of case management with service users who have complex health needs
A clear knowledge and understanding of The National Framework for NHS Continuing Health Care and its application in practice
An understanding of the Mental Capacity Act 2005 and its application
An understanding of commissioning for complex health needs in the context of NHS Continuing Healthcare
Experience of monitoring a budget and understanding of financial systems and processes

Personal Qualities

Essential

Self-motivated and enthusiastic
Adaptability, flexibility to work and ability to cope with uncertainty and change
Works well with others, is positive and helpful, listens, involves, respects and learns from the contribution of others
Consistently looks to improve what they do, look for successful tried and tested ways of working, and also seeks out innovation
Actively develops themselves and supports others to do the same
Understanding of and commitment to equality of opportunity and good working relationships
Professional, calm and efficient manner

Skills and Knowledge

Essential

High level of working knowledge of the relevant legislation and theories underpinning the provision of services to the relevant client group
Demonstrable experience and knowledge of current key policies and priorities within the NHS, especially within Clinical commissioning Groups
A clear knowledge and understanding of service provision available locally, regionally and nationally for the client group
Understanding of relevant current NHS and social care market mechanisms
Good working knowledge of adult safeguarding
Awareness of Data Protection and confidentiality issues
Working knowledge of Microsoft Office with standard keyboard skills
Effective interpersonal and negotiation skills enabling effective communication with clients, other professionals, colleagues, partner agencies, providers and carers.
Excellent written and verbal communication including providing and receiving complex, sensitive or contentious information
Excellent time management skills
Ability to prioritise and to work effectively on own initiative
Ability to work in hostile environments and deal with conflict on a regular basis
Understanding of the commissioning/ procurement process for adults continuing health care packages

Qualifications

Essential

Relevant degree/professional qualification in Nursing*** (local areas may differ/could be Social Work))
Evidence of continuous professional development
Educated to degree level or equivalent level of experience of working at a senior level in a specialist area.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.