Care Coordination Social Worker: Discharge & Resources

Wellstar Health System; Hiram (GA); On-site; USD 60,000 - 80,000; Full time

Job summary

Wellstar Health System is seeking a Care Coordination Social Worker (CC SW) to assess transitional care needs, coordinate across the continuum, and engage patients and families to ensure discharge plans meet needs and resources. You will work with physicians and the care team to develop timely, safe transitions, including end-of-life considerations and community referrals.

The role emphasizes psychosocial assessments, resource navigation, and partnership with RN Case Managers to optimize patient

Qualifications

• Excellent written and verbal communication.
• Ability to work under stress in a fast-paced environment.
• Strong assessment and problem-solving skills.
• Knowledge of local, state and federal regulations.
• Experience coordinating care across the continuum.

Responsibilities

• Discharge planning and resource information for patients.
• Identify and document barriers to timely disposition.
• Coordinate post-acute referrals and transition plans.
• Collaborate with RN Case Manager and care team.
• Document psychosocial assessments in the medical record.
• Participate in interdisciplinary rounds.
• Advise on end-of-life and community resources.

Skills

Communication skills

Assessment skills

Care coordination

Documentation

Interdisciplinary collaboration

Education

Bachelor's Social Work

Master's Social Work

Job description

Wellstar Health System is seeking a Care Coordination Social Worker (CC SW) to assess transitional care needs, coordinate across the continuum, and engage patients and families to ensure discharge plans meet needs and resources. You will work with physicians and the care team to develop timely, safe transitions, including end-of-life considerations and community referrals.

The role emphasizes psychosocial assessments, resource navigation, and partnership with RN Case Managers to optimize patient