Clinical Social Worker: Discharge & Care Coordination

WVU Medicine; Morgantown (WV); On-site; USD 50,000 - 70,000; Full time

Job summary

WVUH West Virginia University Hospitals in Morgantown seeks a social worker to coordinate care across the continuum. You will perform psychosocial assessments, crisis intervention, and develop discharge plans with referrals to post-acute services.

The role requires a Master’s in Social Work and appropriate state licensure; 1–3 years of experience preferred. On-call duties, weekend rotations, and a 40-hour workweek are typical.

Qualifications

• Master's degree in Social Work is required.
• Current social work licensure as required by the state where work is performed.
• WV licensure categories: LGSW/LCSW/LICSW (WV); LMSW/LCSW-C (MD).

Responsibilities

• Manage transition/discharge planning for assigned patients.
• Collaborate with the multidisciplinary team to facilitate discharge planning.
• Monitor patient progress and ensure a patient-focused, high-quality plan of care.
• Maintain knowledge of federal, state, and local social assistance programs.
• Provide education to staff, physicians, patients and families on transition planning.
• Complete timely documentation of interactions and progress per regulatory policies.
• Coordinate referrals to post-acute services (home health, DME, hospice, SNFs, rehab facilities).
• Communicate discharge plans to team, patient, and family.
• Utilize quality screens to identify potential delays and readmissions.
• Assist with financial management and eligibility for social programs.

Skills

Interpersonal skills

Negotiation

Adaptability

Independent judgment

Education

MSW degree

Social work licensure

Job description

WVUH West Virginia University Hospitals in Morgantown seeks a social worker to coordinate care across the continuum. You will perform psychosocial assessments, crisis intervention, and develop discharge plans with referrals to post-acute services.

The role requires a Master’s in Social Work and appropriate state licensure; 1–3 years of experience preferred. On-call duties, weekend rotations, and a 40-hour workweek are typical.