Job Description

This job collaborates with the interdisciplinary team of providers, clinicians, health plans, and external partners while advocating for patients and families/caregivers to coordinate care across the continuum. The incumbent is an integral member of the Care Management team that works to improve the quality of care, patient experience, and the health of populations and individuals by focusing on the social determinants of health impacting wellness. Essential responsibilities include contributing to and/or completing initial and ongoing comprehensive assessment, providing interventions and implementing recommendations after engaging patients and their caregivers/families, focusing on the individual's risk related to social determinants of health to assure successful coordination of care across the continuum (30%). Collaborating to provide the safest transition plan for assigned patients (Inpatient/Observation/ED) to ensure a timely discharge and provide appropriate connection with post-discharge care providers and community-based resources (25%). Educating patient, family/caregiver and physician regarding most appropriate level of care post discharge and how to access community support, advocating for the patient, family/caregiver through effectively communicating with interdisciplinary team members, payers and post-acute partners to assure the safest transition (20%). Serving as a resource to provide counseling and intervention related to treatment decisions and end-of-life issues, driving collaborative conversations to establish goals of care, providing crisis interventions in cases involving Child Abuse and Neglect, Domestic Violence, Adult and Older Adult Abuse, Institutional Abuse Sexual Assault, Mental Health Disorders, Substance Use Disorders, and Identification of a Surrogate Decision Maker/Guardianship (15%). Promoting individual professional growth and development through certification, mentoring/precepting, and/or participation on department/hospital/system committees (5%). Supporting Department based goals that contribute to the success of the organization (5%). Other duties as assigned. Qualifications include a minimum Master's degree in Social Work (with 6 months from hire date to obtain if hired before 4/21/2025), experience in a hospital or health care setting, LSW and/or LCSW required (with 12 months from hire date to obtain if hired before 04/21/2025), and required background clearances (Act 34, Act 33, Act 73).

By applying, you consent to your information being transmitted by Jooble to the Employer, as data controller, through the Employer’s data processor SonicJobs.
See Sonicjobs Privacy Policy at and Terms & Conditions at and SonicJobs Privacy Policy at and Terms of Use at

Job Tags

Similar Jobs