Care Coordination Social Worker MSW

CommonSpirit Health•Lexington, KY

1d•Onsite

About The Position

Saint Joseph Hospital, a 433-bed hospital founded in 1877, is seeking a Care Coordination Social Worker MSW to drive patient well-being and resource navigation. This role directly impacts the holistic care and successful transitions for hospitalized and emergency department patients. The social worker will be a critical member of the Care Coordination and multidisciplinary healthcare teams, ensuring comprehensive support and linkage to essential resources. The position requires strong social work assessment, intervention, and collaboration skills, with an unwavering commitment to patient advocacy, resourcefulness, and organizational values. A professional demeanor, dedication, and proactive approach are essential for fostering effective patient/family support, navigating complex social determinants of health, and ensuring seamless transitions of care for diverse patient populations.

Requirements

Masters Other Social Work (MSW), upon hire
Licensed Social Worker: KY, upon hire
Master Social Worker: KY, upon hire

Nice To Haves

One year of healthcare experience

Responsibilities

Performing social work screenings and interventions for hospitalized and emergency department patients, in consultation with and collaboratively with the Care Coordination and multidisciplinary healthcare teams.
Providing patient/family support and making appropriate referrals.
Conducting thorough social needs screenings.
Facilitating referrals for financial or other identified resource needs.
Arranging family/patient representative meetings with the healthcare team as needed.
Assisting in the post-acute placement of complex discharges.
Engaging appropriate agencies or community resources when patient's social needs are identified.
Providing developmentally appropriate care for all populations served, including planning for safe discharge and continuity of care, and recognizing and planning for the unique needs of all ages, the physically disabled, mentally ill, chronically ill, terminally ill, and vulnerable patients.
Providing patient/family support, patient/family health management education, healthcare team and community education, and case/care management/coordination education and training.
Performing social needs screenings, determining patient functioning and availability of support systems, and supporting in addressing social needs and making related referrals.
Escalating identified cases involving abuse, neglect, trafficking, complex family issues affecting care, grief/bereavement support, adoptions, surrogacy, safe surrender, substance use and abuse, and significant mental health or psychiatric concerns.
Addressing, managing, and referring resources related to social determinants of health (e.g., housing and food insecurity, transportation).
Facilitating interdisciplinary care communication/coordination related to continuity/transitions of care planning and management.
Sharing responsibility for identifying appropriate decision makers if the patient is unable or without capacity.
Facilitating patient decisions and communications regarding post-acute care as a member of the Care Management/Coordination team.
Maintaining professional responsibility for knowledge of community resources related to social work scope of practice and maintaining appropriate up-to-date resource lists.
Educating patients/families about the availability of community resources.
Coordinating mental health services and support.
Assisting in referral and management of grave disability, palliative care/end-of-life, and hospice patient/family needs.
Managing and coordinating discharge/transition planning for socially complex cases.
Engaging in life-care planning.
Providing consultation on healthcare resources.
Educating teams and patients regarding various healthcare-related insurance/support programs (e.g., CCS/Medicare/Medicaid/SSI).
Building and maintaining community relationships to address needs of patients experiencing homelessness and to meet other social needs.