Social Worker - Case Management

Conifer Health Solutions•Modesto, CA

About The Position

The Social Worker facilitates care across the continuum through effective resource coordination, helping patients achieve optimal health, access to care, and appropriate use of resources while respecting patients’ resources and right to self-determination. The role ensures care is provided at the appropriate level based on medical necessity and assesses transition needs to support timely throughput, safe discharge, and prevention of avoidable readmissions. It includes complex psychosocial assessment and intervention. The position integrates national case management standards, including transition management, care coordination, compliance with regulatory and accreditation requirements, education for physicians, patients, families, and caregivers, and participation in planning the social work component of selected hospital programs. The Social Worker also provides staff in-service education and collaborates with community providers to develop educational resources for staff and patients or their representatives.

Requirements

Master of Social Work (MSW).
Demonstrated organizational skills.
Excellent verbal and written communication skills.
Ability to lead and coordinate activities of a diverse group in a fast-paced environment.
Critical-thinking and problem-solving skills.
Computer literacy.

Nice To Haves

A minimum of two years of acute hospital experience is preferred.

Responsibilities

Coordinate care and support efficient care sequencing at the appropriate level of care.
Assess and reassess transition needs, including conducting complex psychosocial assessments and interventions.
Implement or oversee implementation of transition and discharge plans.
Assist with adoption, abuse, and neglect cases through assessment, intervention, and referral to appropriate local, state, or federal agencies.
Lead or facilitate multidisciplinary patient care conferences, including Complex Case Review.
Make appropriate referrals to other departments.
Communicate the plan of care to patients and families.
Collaborate with physicians, office staff, and ancillary departments.
Ensure patient education is completed to support post-acute needs.
Complete timely, accurate, and concise documentation in the Case Management system.
Maintain accurate patient demographic and insurance information.
Precept new staff members and serve as a resource to staff.
Facilitate TEMPO as needed.
Participate in department quality improvement initiatives.
Provide education to physicians, patients, families, caregivers, and staff, and help plan the social work component of selected hospital programs.
Collaborate with community providers to develop educational resources for staff and patients or patient representatives.
Perform other duties as assigned.