Clinical Social Worker II PRN

University of Maryland Medical System; Bel Air (MD); On-site; USD 46,000 - 64,000; Full time

Job summary

The University of Maryland Medical System seeks a skilled Care Coordinator to manage patient transitions and ensure safe discharge planning. You will work with an interdisciplinary team to develop care plans, coordinate follow-up services, and monitor high-risk patients to reduce readmissions.

Responsibilities include comprehensive assessments, patient education, and precise EMR documentation to support continuidad of care and performance goals.

Qualifications

• Master’s degree in Social Work accredited by CSWE.
• LCSW-C licensure from the Maryland Board of Social Work Examiners.
• Minimum three (3) years of post-Master’s experience is required.

Responsibilities

• Screen patients to identify needs and prioritize caseload to identify high risk and rising risk patients.
• Coordinate with interdisciplinary team to develop, revise, and implement discharge interventions to ensure safety and care coordination.
• Oversee Transitions of Care including discharge provisions, follow-up appointments, home health, and transportation.
• Communicate with CRM manager any pertinent findings causing delays in care coordination and LOS.
• Maintain accurate timely documentation of actions/services in the EMR.

Skills

Care coordination

Discharge planning

Communication with physicians

EMR documentation

Patient education

Education

Master’s degree in Social Work

LCSW-C licensure

Tools

EMR systems

Job description

• Screen patients to identify needs and prioritize caseload to identify high risk and rising risk patients.
• Coordinate with interdisciplinary team to develop, revise, (if necessary due to change in patient progress), and implement appropriate discharge interventions to ensure safety and care coordination.
• Accepts responsibility for patients’ Transitions of Care, coordinating provisions for discharge to including follow-up appointments, home health, community services, transportation, etc., in order to maintain continuity of care on identified high risk patients.
• Communicate with CRM manager any pertinent findings causing a delay in care coordination, safe d/c planning, and/or LOS.
• Assessment:
• Completes a thorough assessment with patient’s history including medical, physical, social, emotional, psychological, and financial needs that will assist the care team in developing a care plan.
• Identifies barriers to health care both in social and medical need that focuses on the prevention of readmissions.
• Promotes patient self-management, educating patients on disease, medication, access to care, self-care support, to improve clinical outcomes and increase patient self-efficacy.
• Provide and review the appropriate community resources/services with the patient/family.
• Maintain accurate timely documentation of actions/services in the appropriate EMR and data collection.
• Rounds: (Patient Model of Care, Palliative Care, and long-stay rounds)
• Actively participate in rounds to ensure continuity of care is communicated with other disciplines and to ensure a reduction in LOS.
• Have knowledge of patient plan of care.
• Document appropriately.
• Report patterns of noncompliance.
• Consults regularly with the inpatient provider, PCP, Director and Supervisor, and other team members to ensure that the transition plan remains relevant, appropriate, and responsive to changing patient status and/or goals.
• Establish an effective and appropriate means of communicating and collaborating with physicians, team members, payers and administrators to ensure safe and efficient services.
• Identify need for, arrange, and facilitate peer consultation/health team meeting/family conference when necessary to advance coordination of complex services/resources and medical and/or social issues.
• Develops and maintains collaborative relationships with the post-acute representatives to ensure safe and confidential and transfer is timely.
• Participates in identifying and achieving the departments PI initiatives and goals. Reports and documents process and safety issues in the Events Tracking system.
• Orients new team members and students.
• Maintain professional development best practices and continuing education for care coordination.
• Assist with special projects and other duties as assigned.

Job Requirements

Job Description

• Care Coordination:
• Screen patients to identify needs and prioritize caseload to identify high risk and rising risk patients.
• Coordinate with interdisciplinary team to develop, revise, (if necessary due to change in patient progress), and implement appropriate discharge interventions to ensure safety and care coordination.
• Accepts responsibility for patients’ Transitions of Care, coordinating provisions for discharge to including follow-up appointments, home health, community services, transportation, etc., in order to maintain continuity of care on identified high risk patients.
• Communicate with CRM manager any pertinent findings causing a delay in care coordination, safe d/c planning, and/or LOS.
• Assessment:
• Completes a thorough assessment with patient’s history including medical, physical, social, emotional, psychological, and financial needs that will assist the care team in developing a care plan.
• Identifies barriers to health care both in social and medical need that focuses on the prevention of readmissions.
• Promotes patient self-management, educating patients on disease, medication, access to care, self-care support, to improve clinical outcomes and increase patient self-efficacy.
• Provide and review the appropriate community resources/services with the patient/family.
• Maintain accurate timely documentation of actions/services in the appropriate EMR and data collection.
• Rounds: (Patient Model of Care, Palliative Care, and long-stay rounds)
• Actively participate in rounds to ensure continuity of care is communicated with other disciplines and to ensure a reduction in LOS.
• Have knowledge of patient plan of care.
• Document appropriately.
• Report patterns of noncompliance.
• Consults regularly with the inpatient provider, PCP, Director and Supervisor, and other team members to ensure that the transition plan remains relevant, appropriate, and responsive to changing patient status and/or goals.
• Establish an effective and appropriate means of communicating and collaborating with physicians, team members, payers and administrators to ensure safe and efficient services.
• Identify need for, arrange, and facilitate peer consultation/health team meeting/family conference when necessary to advance coordination of complex services/resources and medical and/or social issues.
• Develops and maintains collaborative relationships with the post-acute representatives to ensure safe and confidential and transfer is timely.
• Participates in identifying and achieving the departments PI initiatives and goals. Reports and documents process and safety issues in the Events Tracking system.
• Orients new team members and students.
• Maintain professional development best practices and continuing education for care coordination.
• Assist with special projects and other duties as assigned.

Qualifications

Work Experience

Education, Experience And Qualifications

• Master’s degree in Social Work accredited by Council on Social Work Education (CSWE).
• LCSW- C (Licensed Certified Social Worker-Clinical) licensure from the Maryland Board of Social Work Examiners.
• Minimum three (3) years of post-Master’s experience is required.

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation

Pay Range: ($33.36 - $46.70)

Other Compensation (if applicable): n/a

Review the 2025-2026 UMMS Benefits Guide

Benefits

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation

Pay Range: ($33.36 - $46.70)

Other Compensation (if applicable): n/a

Review the 2025-2026 UMMS Benefits Guide