The Social Worker supports patients with complex psychosocial needs by assisting with social program eligibility, funding sources, community resources, and transitions of care. They provide crisis intervention and coordinate discharge planning for high-risk patients referred by the interdisciplinary team. Working collaboratively with patients, families, nurses, physicians, and other care team members, the social worker ensures patient-centered, efficient, and cost-effective care throughout the continuum. Under the supervision of the Care Management Supervisor or Manager, they assess post-hospital needs, develop and implement transition plans, and promote smooth, safe discharges that enhance patient satisfaction and reduce readmissions. Key responsibilities include care coordination, discharge planning, and removing barriers to timely care and reimbursement. The social worker educates staff on resource utilization, medical necessity, and discharge regulations, and remains knowledgeable about post-acute services such as Home Health, Hospice, Rehabilitation, and community programs. They uphold quality care standards, regulatory compliance, and exceptional customer service while maintaining respectful professional relationships.
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Job Type
Full-time
Career Level
Mid Level
Industry
Ambulatory Health Care Services
Number of Employees
5,001-10,000 employees