Discharge & Care Coordination Social Worker

gbmc; Towson (MD); On-site; USD 58,000 - 94,000; Full time

Job summary

GBMC HealthCare is seeking a Social Worker for the Continuing Care Department to assess and intervene for seamless post-discharge care. You will collaborate with physicians, nurses, and clinicians on assigned units, interviewing patients and families to develop a continuing care plan.

Responsibilities include educating patients about resources, insurance, advance directives, end-of-life issues, and navigating the system; coordinating care with home health, social services, rehab, and mental

Qualifications

• Master's in Social Work; equivalent experience or certification considered.
• Licensed in Maryland as LMSW or LCSW.
• 1–3 years hospital or health care discharge planning experience.

Responsibilities

• Assess and intervene to ensure continuation of care after hospital discharge.
• Interview patients and families; facilitate family meetings to plan continuing care.
• Educate patients and families about community resources, insurance, advance directives, and end-of-life issues.
• Coordinate complex care plans with home health, social services, rehab, and mental health providers.
• Work as part of a multidisciplinary team and participate in process-improvement initiatives.

Skills

Cultural competency

Basic computer skills

Interview skills

Assessment skills

Counseling

Motivational interviewing

End-of-life discussions

Prioritization

Referral knowledge

Teamwork

Patient education

Education

MSW

LMSW/LCSW licensure

Master's in Social Work

Tools

EMR

Job description

GBMC HealthCare is seeking a Social Worker for the Continuing Care Department to assess and intervene for seamless post-discharge care. You will collaborate with physicians, nurses, and clinicians on assigned units, interviewing patients and families to develop a continuing care plan.

Responsibilities include educating patients about resources, insurance, advance directives, end-of-life issues, and navigating the system; coordinating care with home health, social services, rehab, and mental