Social Worker- Housing Coordinator (Full Time, Day)
About The Position
The Social Worker Housing Coordinator supports patients and families throughout care and recovery, assessing psychosocial and housing needs and coordinating appropriate interventions, care plans, referrals, and discharge or continuing-care arrangements. The position serves ElderONE Hudson and works with patients, families, interdisciplinary teams, care managers, insurance providers, healthcare facilities, and community partners. For ElderONE housing coordination, the role helps reduce hospital and skilled-nursing-facility stays caused by housing barriers. The coordinator develops housing options of varying duration and service levels, coordinates timely transitions into housing, helps participants with housing tours, paperwork, finances, rent, deposits, and representative payee arrangements when needed, and plans proactively for participants at risk of homelessness. The role also works with skilled nursing facilities to identify housing options for patients who no longer want to remain in those facilities. The role is primarily sedentary and office-based, with prolonged sitting, minimal physical effort, and lifting under 10 pounds. It requires fine motor skills for computer, writing, and telephone work, as well as sustained concentration, independent decision-making, and information processing. Administrative healthcare settings may occasionally involve exposure to infectious agents. Some roles may require flexible hours, TB screening, or a valid driver’s license.
Requirements
- A bachelor’s degree in Social Work is required for hires on or after January 1, 2024.
- For hires on or before December 31, 2023, a bachelor’s degree in Social Work or a related degree is required.
- Long-term-care qualification: a bachelor’s degree in Social Work; or a bachelor’s degree in a human-services-related major such as sociology, gerontology, psychology, rehabilitation counseling, or special education, plus one year in a healthcare setting working directly with individuals as a supervised social worker.
- New graduates may provide an official transcript or a letter sent directly by the school registrar confirming program completion; primary-source education verification is required within 90 days of the start date.
- Compassionate, warm, and patient-focused approach.
- Exceptional documentation and planning skills.
- Excellent communication and interpersonal skills.
- Sedentary work requiring prolonged sitting, fine motor skills, clear visual and auditory ability, sustained concentration, frequent interruption management, independent decision-making, and information processing.
Nice To Haves
- One year of experience in a healthcare setting is preferred.
Responsibilities
- Manage referrals for patients with psychosocial needs, identify high-risk patients who have not been referred, determine appropriate interventions, and document actions.
- Assess patient needs through interdisciplinary rounds, chart review, patient and family interviews, and team conferences.
- Conduct and document psychosocial assessments and coordinate assessments and care plans in accordance with social work policies.
- Evaluate patients for an appropriate level of care when indicated and coordinate multidisciplinary and agency case conferences.
- Implement intervention plans in preparation for discharge or continued care, complying with departmental and governmental regulations.
- Work with care managers and health insurance providers to advocate for patients and families and obtain coverage approvals.
- Involve patients and families in treatment planning and execute mutually agreeable discharge or continued-care plans.
- Notify involved parties of discharge within 24 hours of receiving discharge authorization and request necessary paperwork from relevant disciplines.
- Arrange patient transportation when needed and in accordance with hospital procedures.
- Act as a liaison with the community and a referral source.
- Reduce hospital and skilled-nursing-facility days caused by housing barriers by developing housing options with varied lengths of stay and services.
- Coordinate with interdisciplinary teams, discharge planners, and referral partners to support timely transitions into housing.
- Assist participants with housing tours, documentation, paperwork, and financial arrangements, including rent, deposits, and representative payee services when needed.
- Identify participants at risk of homelessness and create proactive mitigation plans to avoid unnecessary skilled-nursing stays or higher levels of care.
- Work with contracted and non-contracted skilled nursing facilities to find housing options for patients who no longer wish to remain in a skilled nursing facility.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
