Sr. ED Care Coordinator – Social Worker – North Fulton – Full-Time, Variable Shift

Wellstar Health System•Roswell, GA

13d

About The Position

The Care Coordination Social Worker Sr. assesses patients’ transitional care needs, coordinates care across the continuum, and engages with patients and families to ensure their needs are met. The role serves as an expert resource for complex patients and situations and consults with care team members regarding psychosocial and resource needs. In partnership with patients and physicians, the social worker assesses, coordinates, and implements timely, safe discharge plans to appropriate next levels of care, incorporating individual needs and available resources. The position provides psychosocial assessments and timely discharge planning; shares information about community services and referrals; and supports patients and families as they navigate psychosocial dynamics and care decisions, including end-of-life planning. The social worker partners with RN Care Coordinators on complex social determinants of health and social needs, and may orient and precept new hires, mentor social workers, and support student interns. Other duties may be assigned. The role includes complex disposition planning, assessment of psychosocial risks and resource availability, coordination with patients, families, physicians, and other care team members, and timely, accurate documentation in the medical record. The social worker also contributes to professional development, departmental goals, protocols, procedures, and performance improvement, and complies with Wellstar Health System policies and standards.

Requirements

Bachelor’s or master’s degree in Social Work; a master’s degree is preferred.
Current BLS, ARC-BLS, or BLS-I certification is required upon hire.
Georgia LMSW or Georgia LCSW license is required upon hire.
At least 2 years of experience in healthcare in an acute care setting, a related field, a skilled care environment, or the community.
Excellent written and verbal communication skills.
Maturity, self-confidence, objectivity, and a positive attitude.
Ability to work independently, function under stress, adapt to change, and work in a fast-paced environment.
Strong assessment, interviewing, organizational, and problem-solving skills.
Knowledge of applicable local, state, and federal regulations.
Knowledge of community and statewide resources and programs.
Ability to collaborate with physicians, care team members, patients, and families across the continuum of care.

Nice To Haves

Background in medical social work in an acute care setting.
Master’s degree in Social Work.
Experience or capability in precepting and mentoring colleagues or student interns.

Responsibilities

Plan complex patient discharges and provide timely resource information for safe transitions to appropriate levels of care.
Identify and document barriers to timely disposition and understand eligibility criteria for private and public resources.
Respond to assistance referrals from RN Care Coordinators, physicians, and the care team.
Participate in interdisciplinary rounds and recommend appropriate care transitions.
Initiate and facilitate post-acute referrals through departmental processes.
Assess financial needs for patients requiring assistance with follow-up care.
Advocate for patients and families and support autonomous healthcare decisions that center the patient’s wishes.
Consider cultural and religious beliefs in service delivery and continuity of care.
Assess psychosocial risk factors and available discharge resources based on preliminary patient screening.
Partner with PAS, financial counselors, and/or UM nurses to assess insurance coverage requirements.
Collaborate with patients, families, physicians, and care team members to support care progression and discharge plans.
Complete and document initial psychosocial and functional assessments; maintain understandable, current records and timely progress notes.
Document services arranged or delivered in the Electronic Health Record and track avoidable days and outcome trends.
Assist with precepting new hires and mentor less senior employees in challenging care situations.
Serve as a preceptor or mentor for student interns.
Complete required competency assessments and mandatory and population-specific education.
Support departmental goals and participate in developing protocols, procedures, and performance improvement initiatives.
Comply with Wellstar Health System policies, standards of work, and code of conduct.
Perform other duties as assigned.