Care Transition & Discharge Social Worker

WVU Medicine Golisano Children's; Bridgeport (WV); Hybrid; USD 55,000 - 75,000; Full time

Job summary

WVU Medicine seeks a social worker to coordinate care across the continuum, performing psychosocial assessments, crisis intervention, resource management, and discharge planning. The role involves collaboration with a multidisciplinary team to ensure timely, patient-centered transitions and appropriate referrals to post-acute services.

The position emphasizes assisting patients with social program eligibility, navigating funding sources, and developing individualized transition plans with

Qualifications

• Master's degree in Social Work.
• Current social worker licensure as required by the state where work is performed.
• WV: Licensed Graduate Social Worker (LGSW), Licensed Certified Social Worker (LCSW) or Licensed Independent Social Worker (LICSW) in WV; MD: LMSW or LCSW-C in Maryland.

Responsibilities

• Manages all aspects of transition/discharge planning for assigned patients with timely escalation when barriers occur.
• Collaborates with the multidisciplinary team to facilitate transitions and discharge for designated caseload.
• Monitors patient progress and ensures the plan of care and services are patient-focused, high quality, efficient, and cost-effective.
• Maintains knowledge of federal, state, and local assistance programs and community resources.
• Educates staff, physicians and patients/families to support effective transition planning.
• Meets with patient/family to assess needs and develop individualized discharge plans in collaboration with the physician team.
• Provides psychosocial assessments and interventions for complex crises including mental health, substance use, adjustment to illness, and grief.

Skills

Social work

Crisis intervention

Case management

Interdisciplinary collaboration

Patient advocacy

Education

Master's degree in Social Work

Job description

WVU Medicine seeks a social worker to coordinate care across the continuum, performing psychosocial assessments, crisis intervention, resource management, and discharge planning. The role involves collaboration with a multidisciplinary team to ensure timely, patient-centered transitions and appropriate referrals to post-acute services.

The position emphasizes assisting patients with social program eligibility, navigating funding sources, and developing individualized transition plans with