Social Worker Case Manager - PRN

About the Role

Inova Fairfax Hospital is seeking a dedicated Experienced Social Worker Case Manager (PRN) to join the Case Management Team. The role evaluates patients’ ability to progress throughout the continuum of care, collaborates with physicians, nursing, and multidisciplinary team members, and provides discharge planning and continuity of care for acute and post‑acute patients.

Responsibilities

• Assess patients' biopsychosocial needs through review of information, personal contact, and interdisciplinary collaboration.
• Communicate routinely with patients, families, and care team members about care plans, progress toward treatment goals, concerns, and problem‑solving.
• Ensure all options supporting a successful transition are communicated, documented, and coordinated to maintain continuity of care.
• Refer cases and issues appropriately to resolve barriers to care progression and act as an advocate for patients.
• Conduct preliminary risk screenings and assess psychosocial risk factors, including functional levels, support systems, reactions to illness, and coping ability.
• Intervene regarding emotional, social, and financial consequences of illness or disability.
• Provide counseling and interventions related to treatment and end‑of‑life decisions, promoting patient/family empowerment and autonomy.
• Develop and execute discharge planning and continuity of care for acute and post‑acute settings.
• Initiate and facilitate referrals to clinics, home health, hospice, SNF, acute rehab, LTAC, TCM, medical equipment, and supplies as indicated.
• Collaborate with the interdisciplinary team, patients, and families to assess and coordinate discharge planning needs and post‑discharge services.
• Document discharge planning information in the medical record according to department standards.
• Coordinate services and serve as a key liaison between patients, families, and interdisciplinary healthcare members.
• Perform other duties as assigned.

Minimum Qualifications

• Certification: Basic Life Support – required upon start.
• Experience: 1 year of clinical care or clinical case management experience.
• Education: Master’s Degree in Social Work (MSW).

Preferred Qualifications

• At least 1 year of inpatient case management and discharge planning experience.

Benefits

• Medical, dental, and vision coverage plus a robust wellness program.
• Retirement plan with Inova matching the first 5 % of eligible contributions from day one.
• Tuition and student loan assistance: up to $5,250 per year for education and up to $10,000 for student loans.
• Mental health support: 25 coaching or therapy sessions per person per year at no cost for team members, spouses/partners, and children.
• Work/life balance: paid time off, paid parental leave, and flexible work schedules.

About Us

Inova is Northern Virginia’s leading nonprofit healthcare provider, employing over 26,000 team members who deliver world‑class care. Recognized nationally for safety, quality, and patient experience, Inova is also a top employer in the D.C. metro area. We are committed to professional development, compassionate care, and shaping a better future for healthcare.