Care Coordination Social Worker — Discharge & Support

South Shore Health; Norwell (MA); On-site; USD 73,000 - 104,000; Full time

Job summary

South Shore Health’s SSH Population Health department seeks a Clinical Social Worker to advocate for patients and coordinate services with an RN Case Manager. On-site role with a 4-5 day presence, focused on preventing readmissions and ensuring smooth transitions to home or community care.

The ideal candidate holds an MSW and independently licensed status (LICSW/LMHC) with healthcare 경험 and strong communication.

Qualifications

• Master's degree in Social Work required.
• Must be independently licensed (LICSW or LMHC).
• Experience with pediatric, elder, and diverse community populations recommended.

Responsibilities

• Coordinate psychosocial assessments within 24 hours of patient admission or referral.
• Attend and participate in Interdisciplinary Rounds and CMS Teams discussions.
• Coordinate discharge planning with Case Management and other departments.
• Document patient outcomes and interventions clearly in the EMR.
• Support transition of care from hospital to home/community with appropriate referrals.

Skills

Excellent communication

Autonomy

Multidisciplinary collaboration

Education

MSW degree

Job description

South Shore Health’s SSH Population Health department seeks a Clinical Social Worker to advocate for patients and coordinate services with an RN Case Manager. On-site role with a 4-5 day presence, focused on preventing readmissions and ensuring smooth transitions to home or community care.

The ideal candidate holds an MSW and independently licensed status (LICSW/LMHC) with healthcare 경험 and strong communication.