LMSW - Care Coordinator - Emergency

3710 Paulding Medical Center, Inc.•Hiram, GA

About The Position

The Care Coordination Social Worker Sr. (SW Sr.) assesses patients’ transitional care needs, coordinates care across the continuum, and engages patients and families to ensure care needs are met. The role serves as an expert resource for complex patients and situations, consulting with other care team members about psychosocial and resource needs. In conjunction with patients and physicians, the SW Sr. assesses, coordinates, and implements timely, safe discharge plans to the next appropriate level of care, integrating the transitional care plan into individualized discharge plans based on patient needs and available resources. The position provides psychosocial assessments and timely planning to advance discharge plans; shares information about community-based services and offers guidance on factors affecting patient and family psychosocial dynamics. It provides expertise and resources related to psychosocial and discharge needs, end-of-life planning, and other resource needs, including support for patient and family decision-making. The SW Sr. partners with RN Care Coordinators on complex social determinants of health, situational dynamics, and social needs, and may assist with orientation and precepting. The role also mentors social workers in case reviews and challenging situations, including suicidal ideation, bereavement risk, cultural or language barriers, and abuse cases. Responsibilities include complex disposition planning, psychosocial and resource assessment, collaboration with patients, families, physicians, and care teams, and accurate and timely documentation in the medical record and Electronic Health Record. The position participates in interdisciplinary rounds, facilitates post-acute referrals, assesses financial needs and insurance requirements, identifies barriers to discharge, tracks avoidable days, and supports professional development, departmental goals, protocols, and performance improvement. Other duties may be assigned.

Requirements

Bachelor's degree in Social Work or a Master's degree in Social Work; a master's degree is preferred.
At least 2 years of experience in healthcare in an acute care setting, related field, skilled care environment, or community.
BLS, ARC-BLS, or BLS-I certification required upon hire.
Georgia LMSW or Georgia LCSW license required upon hire.
Excellent written and verbal communication skills.
Maturity, self-confidence, objectivity, and a positive attitude.
Ability to work independently, handle stress and change, and function 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.

Nice To Haves

Background in medical social work in an acute care setting.
Master's degree in Social Work.

Responsibilities

Assess patients’ transitional care needs and psychosocial risk factors, including available resources to support discharge.
Coordinate care across the continuum and develop timely, safe, individualized discharge plans with patients, families, physicians, and the care team.
Provide psychosocial assessments and document assessments, progress notes, patient and family interactions, and arranged or delivered services in the medical record and Electronic Health Record.
Provide resource information and guidance on community-based services, post-acute placements, financial assistance, end-of-life care planning, and other psychosocial or discharge needs.
Identify and document barriers to timely disposition and understand eligibility processes for private and public local, state, and federal resources.
Respond to referrals for patient assistance from RN Care Coordinators, physicians, and the care team.
Participate in interdisciplinary rounds to confirm estimated discharge dates and recommend appropriate levels of care.
Initiate and facilitate post-acute referrals through departmental processes.
Assess financial needs for patients requiring assistance with follow-up care and partner with the PAS, financial counselor, and/or UM nurse to assess insurance and coverage requirements.
Advocate for patients and families and support autonomous healthcare decisions, respecting patient wishes and cultural or religious beliefs.
Track avoidable days and report trends that lead to undesired outcomes.
Assist leadership with precepting new hires and mentor new and less senior employees; serve as a preceptor or mentor for student interns.
Complete required competency assessments and education, support departmental goals, and participate in developing protocols, procedures, and performance improvement initiatives.
Comply with Wellstar Health System policies, standards of work, and code of conduct; perform other duties as assigned.