Social Worker I (Outpatient Clinics)

About the role

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One! We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South. The Social Worker (MSW) is responsible for supporting safe, timely, and effective patient transitions throughout the acute care episode. This role focuses on psychosocial assessment, discharge planning, resource coordination, and patient/family support. The Social Worker collaborates with the interdisciplinary team to reduce barriers to care, prevent avoidable readmissions, and promote optimal patient outcomes. This position does not perform clinical therapy, diagnosis, or licensed clinical interventions. Models appropriate behavior as exemplified in MLH Mission, Vision and Values. Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence.

Responsibilities

• Conducts psychosocial assessments to identify barriers to discharge, including social, financial, environmental, and support needs.
• Develops individualized discharge plans in collaboration with RN Case Managers, physicians, nursing, therapy, and other team members.
• Coordinates post-acute services such as home health, DME, transportation, community resources, and follow-up appointments.
• Ensures timely communication with families, caregivers, and external providers.
• Facilitates safe transitions to SNF, IRF, LTACH, or home settings.
• Provides education on available resources, benefits, and community programs.
• Assists patients and families with advance care planning discussions (non-clinical guidance only).
• Supports patients experiencing psychosocial stressors related to hospitalization, illness, or caregiving needs.
• Advocates for patient rights, preferences, and culturally appropriate care.
• Identifies financial, housing, transportation, and social support needs.
• Connects patients to community agencies, social service programs, and charitable resources.
• Coordinates with insurance case managers as needed for authorizations and benefits clarification.
• Assists with applications for Medicaid, disability, or other assistance programs (as allowed by hospital policy).
• Participates in daily rounds, huddles, and care coordination meetings.
• Communicates patient needs, barriers, and discharge readiness to the care team.
• Works closely with RN Case Managers on complex cases requiring both clinical and psychosocial oversight.
• Completes timely and accurate documentation in the electronic medical record.
• Adheres to CMS, Joint Commission, and hospital policies related to discharge planning and patient rights.
• Supports hospital initiatives such as readmission reduction, length-of-stay management, and value