Discharge & Care Transitions Social Worker

HCA Houston Healthcare; Webster (TX); On-site; USD 52,000 - 76,000; Full time

Benefits offered by this job

Medical, prescription, dental, vision

Behavioral health and telemedicine

Paid time off and family leave

401(k) with 100% match on 3–9%

Job summary

HCA Houston Healthcare Clear Lake is seeking a Social Worker (BSW) to promote patient-centered care, assess psychosocial needs and coordinate post-acute services. You will act as a liaison among patients, families and community resources, developing discharge plans and ensuring smooth care transitions in Med/Surg units.

The role emphasizes collaboration with multidisciplinary teams, patient education, and advocacy for patient preferences and values, within a comprehensive hospital setting.

Qualifications

• LBSW licensed social worker credential required.
• Bachelor's degree in social work or related field.

Responsibilities

• You will work collaboratively with RN case managers, acute care nurses, physicians, insurance companies, and other staff members to proactively identify and address patient needs.
• You will identify and address barriers to discharge and recovery. These barriers include financial, emotional, psychosocial, medical, and spiritual.
• You will perform thorough assessments and develop appropriate discharge plans for high-risk patients with discharge planning or psychosocial needs.
• You will obtain input from the RN case manager to ensure the discharge plan is appropriate and aligns with the patient care plan. You will reassess and modify the patient discharge plan as needed, in conjunction with the clinical team.
• You will participate in the interdisciplinary care planning process and perform proactive discharge planning.
• You will provide education to patients and caregivers regarding community resources and post-acute level of care criteria, benefits, and coverage.
• You will coordinate and facilitate meetings between the care team and patients/families/caregivers. You will assist patients and families in making difficult decisions while honoring their preferences and values.

Skills

LBSW

Education

Bachelor's Degree

Licensed Baccalaureate Social Worker (LBSW)

Job description

HCA Houston Healthcare Clear Lake is seeking a Social Worker (BSW) to promote patient-centered care, assess psychosocial needs and coordinate post-acute services. You will act as a liaison among patients, families and community resources, developing discharge plans and ensuring smooth care transitions in Med/Surg units.

The role emphasizes collaboration with multidisciplinary teams, patient education, and advocacy for patient preferences and values, within a comprehensive hospital setting.