Care Management Social Worker

Role Overview: A PRN/As Needed Care Manager responsible for coordinating patient care across the continuum to ensure safe transitions and optimal outcomes. Key Responsibilities Conduct clinical and psychosocial assessments to evaluate patient needs.Develop and implement individualized care plans in collaboration with healthcare team members.Coordinate with physicians, nurses, social workers, and community partners to facilitate patient care.Educate patients and families about care processes and post-acute services.Arrange and support post-acute services and complex discharge planning.Address barriers to care to improve patient outcomes.Maintain thorough documentation in the EMR and uphold patient-centered values. Qualifications & Skills Strong clinical assessment and care planning skills.Excellent communication and collaboration abilities.Ability to educate and advocate for patients and families.Knowledge of healthcare resources, discharge procedures, and documentation standards.Flexible, adaptable, and patient-centered approach to care coordination.