Care Coordinator Social Worker

Wellstar Health System•Marietta, GA

About The Position

The Care Coordination Social Worker assesses patients’ transitional care needs, coordinates care across the continuum, and works with patients and families to ensure care needs are met. The role provides psychosocial and resource support to patients and serves as a consultant to other care team members. In partnership with the patient and physician, the social worker assesses, coordinates, and implements a timely, safe discharge plan to the next appropriate level of care, integrating transitional care into an individualized plan based on patient needs and available resources. The social worker completes psychosocial assessments and supports timely discharge planning; provides information about community-based services, financial and other resources, post-acute placements, and end-of-life care; and helps patients and families navigate psychosocial dynamics and multi-system factors. The role partners with the RN Case Manager on complex social determinants of health, situational dynamics, and social needs. The position also participates in interdisciplinary planning, documentation, professional development, and performance improvement activities.

Requirements

Bachelor’s degree in Social Work; a Master’s degree in Social Work is preferred.
BLS, American Red Cross BLS, or BLS Instructor certification required upon hire.
At least 1 year of experience in healthcare in an acute care setting, a related field, a skilled care environment, or a community or educational internship in care coordination.
Excellent written and verbal communication skills.
Maturity, self-confidence, objectivity, and a positive attitude.
Ability to work independently, function under stress, adapt to change, and work in a fast-paced environment.
Strong assessment, interviewing, organizational, and problem-solving skills.
Knowledge of local, state, and federal regulations.
Knowledge of community and statewide resources and programs.
Ability to collaborate with physicians, care team members, patients, and families throughout the continuum of care.

Nice To Haves

Licensed Clinical Social Worker (LCSW) in Georgia preferred.
Licensed Master Social Worker (LMSW) in Georgia preferred.
Background in medical social work in an acute care setting highly preferred.

Responsibilities

Assess patients’ psychosocial risk factors, functional needs, and available resources to support discharge.
Collaborate with patients, families, physicians, and care team members to establish and support care progression and discharge plans.
Implement discharge planning and provide resource information in a timely and efficient manner.
Identify and document barriers to timely disposition.
Apply knowledge of eligibility processes and criteria for private, local, state, and federal resources to plan safe and appropriate transitions.
Respond to patient assistance referrals from RN Care Coordinators, physicians, and the care team.
Participate in interdisciplinary rounds to confirm estimated discharge dates and recommend appropriate levels of care for transition.
Initiate or facilitate post-acute referrals through departmental processes.
Assess financial needs for patients who require assistance with follow-up care across the continuum.
Advocate for and partner with patients and families to support autonomous healthcare decisions centered on the patient’s wishes.
Respect cultural and religious beliefs in providing service and continuity of care.
Participate in developing protocols, procedures, and performance improvement activities to optimize patient outcomes.
Document initial psychosocial and functional assessments, progress notes, patient and family interactions, and arranged or delivered services in the Electronic Health Record.
Maintain current, clear, concise, timely, and accurate records; track avoidable days and report trends that contribute to undesired outcomes.
Complete initial and ongoing competency assessments and required mandatory and population-specific education.
Support departmental goals and serve as a preceptor or mentor for social work students, when appropriate.
Comply with Wellstar Health System policies, standards of work, and code of conduct; perform other duties as assigned.