SNF, Social Worker
About The Position
The Post-Acute Network Care Coordinator (Licensed Social Worker) plays a critical role in managing day-to-day skilled nursing facility (SNF) patient populations. This role is responsible for coordinating care, facilitating discharge planning, and addressing psychosocial and environmental barriers to ensure patients receive the most appropriate level of care. Working closely with SNF staff, physicians, and interdisciplinary teams, the Care Coordinator drives efficient length of stay, supports safe transitions, and helps prevent avoidable hospital readmissions. This role partners with an RN Case Manager, who provides clinical oversight and support for high-risk or complex medical needs requiring escalation.
Requirements
- Licensed Clinical Social Worker (LCSW) or Licensed Social Worker (LSW) – State of Illinois- Required
- Strong understanding of SNF workflows, discharge planning, and care transitions
- Excellent communication and interpersonal skills across interdisciplinary teams
- Ability to assess psychosocial needs and navigate community resources
- Strong organizational and time management skills across multiple facilities
- Ability to prioritize, problem-solve, and escalate appropriately
- Comfort working in a fast-paced, field-based environment
- Proficiency in: EPIC or other EMR systems (preferred)
- Microsoft Office Suite (Excel, Word, PowerPoint)
- 2–3 years of experience in: Care coordination, Case management, SNF, hospital, or post-acute settings
- Experience with discharge planning and transitions of care strongly preferred
- Experience working in value-based care or managed populations preferred
Nice To Haves
- EPIC or other EMR systems
- Experience working in value-based care or managed populations
Responsibilities
- Manage a daily/weekly census of patients across assigned SNF facilities
- Serve as the primary point of contact for day-to-day coordination within SNFs
- Maintain an active patient tracking system and provide regular status updates
- Lead discharge planning efforts in collaboration with SNF interdisciplinary teams
- Identify and address barriers to timely discharge (social, environmental, logistical)
- Coordinate post-discharge services including: Home Health, Outpatient follow-up, Community resources
- Facilitate warm handoffs to Duly Care Management teams upon discharge
- Assess patients’ psychosocial, environmental, and support needs
- Advocate for appropriate level of care based on patient goals and clinical status
- Escalate complex medical or high-risk cases to RN Case Manager for clinical review
- Collaborate with SNF staff, physicians, and care teams to align on care plans
- Participate in facility rounds and case discussions
- Communicate updates, risks, and opportunities in real time
- Support appropriate utilization of SNF services
- Identify opportunities to reduce unnecessary length of stay
- Align discharge timing with clinical readiness and patient goals
- Maintain accurate and timely documentation
- Track and report patient outcomes and key metrics
- Perform additional duties as assigned
Benefits
- Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
- Access to a mental health benefit at no cost.
- Employer provided life and disability insurance.
- $5,250 Tuition Reimbursement per year.
- Immediate 401(k) match.
- 40 hours paid volunteer time off.
- A culture committed to community engagement and social impact.
- Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
