Lead Social Worker / Transitional Care Registered Nurse

Ivinson Memorial Hospital•Laramie, WY

5d•Onsite

About The Position

Ivinson Memorial Hospital is seeking a Lead Social Worker / Transitional Care Registered Nurse to provide operational and clinical leadership for the inpatient social work team and transitional care nurse (TCN) team. This role oversees daily operations of inpatient transitions of care and social work services across various units, including medical-surgical, intensive care, emergency department, Women and Children Center, and behavioral health units. The position also collaborates with the oncology department as needed and supervises the transitional care team responsible for discharge planning, care coordination, and post-acute transition activities. The goal is to ensure timely, patient-centered discharge planning and care coordination, promote interdisciplinary collaboration to improve patient outcomes, and provide coaching and professional development for the team. The role also involves ensuring compliance with regulatory standards, leading quality improvement initiatives, and serving as a resource for complex care management issues. Collaboration with leadership, finance, utilization management, and community agencies is essential, as is participation in budget development and hospital committees.

Requirements

Master’s degree in Social Work (BSW) or Bachelor of Science in Nursing (BSN) required.
Minimum of five (5) years of progressively responsible experience in acute care hospital social work, case management, discharge planning, care coordination, or transitional care.
Demonstrated experience managing complex discharge planning and interdisciplinary care coordination.
For Social Work Candidate: Current Licensed Clinical Social Worker (LCSW) in the state of Wyoming.
For Nursing Candidate: Current Wyoming Registered Nurse (RN) license.
Current Basic Life Support (BLS) certification if required by organizational policy.
Comprehensive knowledge of acute care case management, discharge planning, psychosocial assessment, care coordination, and utilization management principles.
Knowledge of federal and state regulations, CMS Conditions of Participation, Joint Commission standards, EMTALA, patient rights, and discharge planning requirements.
Strong understanding of post-acute care resources, community agencies, behavioral health services, long-term care, home health, hospice, rehabilitation, and skilled nursing placement.
Demonstrated leadership, team-building, conflict resolution, and employee development skills.
Excellent critical thinking and clinical decision-making abilities.
Strong organizational skills with the ability to manage competing priorities.
Excellent verbal, written, and interpersonal communication skills.
Ability to build collaborative relationships across multidisciplinary teams and physician groups.
Proficiency in electronic health record (EHR) systems and Microsoft Office applications.
Ability to analyze data, interpret performance metrics, and develop action plans for continuous improvement.
Ability to maintain confidentiality and exercise sound judgment in complex clinical and operational situations.
Commitment to patient-centered care, professional ethics, diversity, equity, and continuous quality improvement.

Nice To Haves

Leadership or management education preferred.
Leadership, supervisory, charge, or program coordination experience preferred.
Experience working across multiple inpatient service lines preferred.
Experience with quality improvement initiatives, regulatory compliance, and performance metrics preferred.

Responsibilities

Provides operational and clinical leadership for the inpatient social work team and transitional care nurse (TCN) team.
Oversees daily operations of inpatient transitions of care and social work services across the medical-surgical, intensive care, emergency department, Women and Children Center and behavioral health units.
Collaborates and supports the oncology department as needed.
Supervises transitional care team responsible for discharge planning, care coordination, and post-acute transition activities.
Ensures timely, patient-centered discharge planning and care coordination in collaboration with physicians, nursing, therapy services, case management, and community partners.
Coordinates staffing, scheduling, workload distribution, and coverage to ensure appropriate patient support across all areas of service.
Monitors patient progression through the continuum of care to identify and address barriers to safe, timely discharge.
Promotes interdisciplinary collaboration to improve patient outcomes, reduce avoidable readmissions, decrease excessive days in acute and elevate the patient experience.
Provides coaching, mentoring, performance management, and professional development team.
Participates in recruitment, onboarding, competency assessment, and retention of department staff.
Ensures compliance with all applicable federal, state, regulatory, accreditation, and organizational standards, including CMS Conditions of Participation and Joint Commission requirements.
Leads quality improvement initiatives designed to improve care transitions, patient safety, and operational efficiency.
Serves as a resource for complex psychosocial, discharge planning, guardianship, placement, behavioral health, and ethical care management issues.
Collaborates with physician leadership, nursing leadership, finance, utilization management, and community agencies to optimize care coordination.
Assists with budget development, resource management, and departmental strategic planning.
Participates in hospital committees, interdisciplinary rounds, and organizational initiatives.
Performs other duties as assigned.

Benefits

Full medical, dental, and vision insurance
Retirement plans
Paid time off
Tuition reimbursement opportunities
403(b) matching
Employer-paid life and long-term disability insurance
Yearly work anniversary pay increases
Education Reimbursement up to $2,500 annually
Retirement plan participation
Free certification classes
Health and Wellness discounts at local gyms
Discounts at select mobile networks, local vendors, and Elitch Gardens
Mental Health: 6 free confidential, in-person counseling sessions offered by Pathways annually
Financial Counseling: free services through WellCents to help you take control of your financial journey
Legal assistance and will preparation services
Student Loan Forgiveness: Ivinson Memorial Hospital is a qualifying employer for the federal Public Service Loan Forgiveness (PSLF) program