Care Coordination Social Worker: Discharge & Transitions

2310 AU Medical Center, Inc.; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

Wellstar Health System is seeking a Care Coordination Social Worker to assess transitional care needs, coordinate care across the continuum, and engage patients and families to ensure discharge plans meet needs.

The role provides psychosocial assessments, connects patients with community resources, and collaborates with RN Case Managers and physicians to optimize transitions and support end-of-life and financial planning.

Qualifications

• Bachelor's or Master's in Social Work required; LCSW/LMSW preferred.
• Current BLS certification required upon hire.
• Healthcare social work experience in acute care settings preferred.
• Excellent communication and interpersonal skills.
• Ability to collaborate with physicians and care teams.

Responsibilities

• Provide psychosocial assessments and timely discharge planning.
• Assist with community resource referrals and financial assistance needs.
• Collaborate with RN Case Managers, physicians, and care teams.
• Support end-of-life care planning and complex social determinants.
• Document clearly in the electronic health record and track outcomes.

Skills

Communication skills

Assessment skills

Care coordination

Interdisciplinary collaboration

Regulatory knowledge

Community resources knowledge

Discharge planning

Education

Bachelor's Social Work

Master's Social Work

BLS Certification

LCSW/LMSW preferred

Job description

Wellstar Health System is seeking a Care Coordination Social Worker to assess transitional care needs, coordinate care across the continuum, and engage patients and families to ensure discharge plans meet needs.

The role provides psychosocial assessments, connects patients with community resources, and collaborates with RN Case Managers and physicians to optimize transitions and support end-of-life and financial planning.