Care Coordination Social Worker — Hospital & Community

Advocate Health; Elkhorn (WI); On-site; USD 55,000 - 75,000; Full time

Job summary

Advocate Health in Wisconsin seeks a licensed master’s social worker to provide psychosocial assessments, discharge planning, and care coordination within a multidisciplinary team. You will assess patient and family needs, determine interventions, and ensure appropriate post-acute connections.

The role emphasizes collaboration with healthcare professionals, resource navigation, education on Advance Directives, and maintaining licensure through ongoing professional development.

Qualifications

• Master’s degree in social work from a CSWE-accredited school.
• 1 year of social work experience in healthcare.
• IL-LSW eligible or WI Social Work Certification preferred (state licensure).

Responsibilities

• Provides social work services including psychosocial assessments, screening, needs evaluation, interventions and discharge planning.
• Collaborates with multidisciplinary health care team to coordinate post-acute placement, home care, and community resources.
• Maintains knowledge of community resources, laws, and regulations impacting care; connects patients/families to appropriate services and post-acute providers.
• Documents activities according to department standards; communicates effectively with patients, families, and providers to resolve continuity of care issues.
• Manages patient progression toward optimized length of stay and appropriate care level; coordinates care within an ACO environment to support outcomes.
• Provides education to patients/families about Advance Directives and supports execution of these documents when appropriate; participates in related legal proceedings.
• Maintains professional standards and completes continuing education to maintain licensure and enhance practice.

Skills

Social work principles

Time management

Documentation skills

Team collaboration

Safety compliance

Education

MSW CSWE-accredited

Job description

Advocate Health in Wisconsin seeks a licensed master’s social worker to provide psychosocial assessments, discharge planning, and care coordination within a multidisciplinary team. You will assess patient and family needs, determine interventions, and ensure appropriate post-acute connections.

The role emphasizes collaboration with healthcare professionals, resource navigation, education on Advance Directives, and maintaining licensure through ongoing professional development.