Discharge & Care Coordination Social Worker

Naswtx; Bridgeport (WV); On-site; USD 65,000 - 90,000; Full time

Job summary

UHC United Hospital Center in West Virginia is seeking a social worker to coordinate care for WVU Medicine patients. The role includes psychosocial assessments, crisis intervention, discharge planning, and referrals to community resources.

You will work with a multidisciplinary team to develop individualized transition plans and ensure smooth, patient-centered care across settings. Responsibilities cover complex cases, documentation, and collaboration with care managers, families, and providers

Qualifications

• Master's degree in Social Work or equivalent.
• Current social worker licensure as required by the state of practice.

Responsibilities

• Coordinate transition/discharge planning for assigned patients.
• Collaborate with multidisciplinary team to facilitate discharge processes.
• Monitor patient progress and ensure patient-centered care.
• Maintain knowledge of federal/state/community resources and programs.
• Provide education to staff, physicians, patients, and families on transition planning.
• Meet with patients/families to develop individualized plans with the physician team.
• Offer social work assessment and interventions for crises, including mental health or substance use.
• Communicate with post-acute providers and payors as needed.
• Document interactions and progress per policy; assist with powers of attorney and advance directives.
• Coordinate referrals to post-acute services (home care, hospice, SNF, etc.).
• Address complex family dynamics impacting care and discharge planning.
• Collaborate to manage financial assistance and entitlements as needed.
• Ensure compliance with payer regulations and avoid denials.
• Educate hospital staff and physicians on managed care principles.
• Participate in on-call and weekend/holiday rotations.

Skills

Interpersonal communication

Diversity and inclusion

Team collaboration

Education

Master's in Social Work

State social work licensure

Job description

UHC United Hospital Center in West Virginia is seeking a social worker to coordinate care for WVU Medicine patients. The role includes psychosocial assessments, crisis intervention, discharge planning, and referrals to community resources.

You will work with a multidisciplinary team to develop individualized transition plans and ensure smooth, patient-centered care across settings. Responsibilities cover complex cases, documentation, and collaboration with care managers, families, and providers