Social Worker II

About the Role

The Social Worker facilitates patient care across the continuum by coordinating resources to promote optimal health, access, and appropriate resource utilization, respecting patient self-determination.

Responsibilities

• Conduct comprehensive psycho-social assessments and interventions to support timely discharge and prevent avoidable readmissions.
• Assess patient transition needs, including identifying at-risk individuals for readmission.
• Manage complex transition planning, including interventions related to adoption, abuse, and neglect cases, with appropriate referrals.
• Oversee and facilitate multidisciplinary care conferences, ensuring effective communication and care coordination.
• Collaborate with patients, families, and healthcare teams to communicate care plans and complete education for post-acute needs.
• Ensure accurate documentation within the case management system and maintain patient demographic and insurance information.
• Lead patient populations or teams, ensure compliance with regulatory standards, and support quality improvement initiatives.

Requirements

• Master's of Social Work (MSW) and active licensure/certification as required by law.
• Preferred: 2 years of hospital experience and accreditation as an Accredited Case Manager (ACM).