Discharge & Care Coordination Social Worker II

Cape Fear Valley Health System; United States; On-site; USD 60,000 - 75,000; Full time

Benefits offered by this job

Relocation assistance available

Equal Opportunity Employer

Job summary

Cape Fear Valley Health System seeks a social worker to plan services for targeted populations and provide psychosocial assessments, crisis intervention, discharge planning, and referrals to patients and families in need of assistance.

Responsibilities include interviews, proactive screenings, documentation, and coordinating post‑acute care across the continuum to meet patient needs and ensure quality care.

Qualifications

• Bachelor’s degree in Social Work required
• MSW preferred
• Professional Certification in Case Management or Social Work (CSW, CCM, ACM) preferred
• 3 years’ experience in Social Services, Home Health, Hospice, SNF, or Acute Care required
• Hospital social work experience preferred
• Proficiency in reading, writing, and speaking English

Responsibilities

• Conduct face‑to‑face interviews with patients and families for discharge planning
• Screen and assess clinical, psychosocial, and discharge needs
• Document assessments, plans, and progress; reassess as needed
• Initiate referrals and consultations for safe discharge or transfer
• Provide information and education on community resources for post‑acute care
• Coordinate Home Health, Hospice, DME, Rehab, and other placements
• Collaborate with healthcare team to meet patient needs and maintain Joint Commission standards

Skills

English proficiency

Interpersonal communication

Negotiation skills

Organization & time management

Advocacy skills

Education

Bachelor’s degree in Social Work

MSW preferred

Social Work certification preferred

Tools

Microsoft Office

Midas

ProviderLink

ValleyLink

eHIM

SMS

Job description

Cape Fear Valley Health System seeks a social worker to plan services for targeted populations and provide psychosocial assessments, crisis intervention, discharge planning, and referrals to patients and families in need of assistance.

Responsibilities include interviews, proactive screenings, documentation, and coordinating post‑acute care across the continuum to meet patient needs and ensure quality care.