Discharge Planner - Medical Social Worker

Marion County Public Health Department; Indianapolis (IN); On-site; USD 52,000 - 78,000; Full time

Job summary

Eskenazi Health is seeking a Discharge Planner - Medical Social Worker to provide comprehensive social services for patients and families, aiding in overcoming barriers to optimal health outcomes. The role supports age-appropriate care across the patient spectrum with a focus on discharge planning and coordinated care.

The position requires an MSW and active social work licensure, with preferred experience in healthcare settings spanning pediatric to geriatric care.

Qualifications

• Master’s in Social Work (MSW) required.
• Active licensure as a Licensed Social Worker or Clinical Social Worker.
• Healthcare social work experience, pediatric/adult/geriatric preferred.

Responsibilities

• Interviews hospital patients and families during inpatient or observation admission.
• Manages assignment of specified unit or clinic, ensuring identified needs are assessed and evaluated.
• Initiates social service plans with medical, nursing and health care personnel using assessments and care plans.
• Coordinates the overall interdisciplinary plan of care from admission to discharge.
• Liaises between patient/family and healthcare personnel to ensure timely care.
• Coordinates discharge plans to meet social and emotional needs for safe discharge.
• Assists patients and families in understanding medical implications on lifestyle.
• Documents services in clinical records.

Skills

Analytical skills

Psychosocial assessment

Counseling skills

Interdisciplinary collaboration

Knowledge of state/federal laws

Education

Master's in Social Work (MSW)

Job description

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Why Eskenazi Health?

We asked Christia , Chief Human Resources Officer: Q Why Eskenazi Health? Employee Q&A

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What do you enjoy most about your role with Eskenazi Health Primary Care and working with the community?

We asked Dawn, CEO - Eskenazi Health Center: Q What do you enjoy most about your role with Eskenazi Health Primary Care and working with the community? Employee Q&A

Date: Oct 12, 2026

Location: Indianapolis, IN, US, 46202

Organization: HHC

Sub-Division:Hospital

Schedule:Full Time

Shift:Days

Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 333-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus including at a network of Eskenazi Health Center sites located throughout Indianapolis.

FLSA Status

Exempt

Job Role Summary

The Discharge Planner - Medical Social Worker is responsible for providing comprehensive social services which assist patients, clients and their families to find practical ways of overcoming social, emotional and environmental barriers to optimum functioning and attainment of health. The Discharge Planner - Medical Social Worker alters activities/behaviors to reflect and ensure adequate care and services appropriate to the age of patients served (i.e. neonatal, infant, pediatric, pre-school, school age, adolescent, adult, geriatric).

Essential Functions and Responsibilities

• Interviews hospital patients and their families during the course of an inpatient or observation admission
• Responsible for managing assignment of specified unit or clinic, ensuring that 100% of patients with an identified need have been assessed and evaluated
• Initiates social service plans for patients/clients through professional collaboration with medical, nursing and health care personnel utilizing screening questionnaires, diagnostic assessments and individualized therapeutic care plans
• Coordinates the overall interdisciplinary plan of care for a patient from admission to discharge
• Serves as a liaison between patient/family and healthcare personnel to ensure necessary care is provided promptly and effectively
• Coordinates discharge plans to meet the patients social and emotional needs to ensure a safe and effective discharge
• Assists patients and families in understanding the implications and complexities of their medical situation and its impact on their current lifestyle
• Provides direction in the selection, analysis, summarization and presentation of patient/client and related information for service delivery planning, case conferences and professional consultation
• Provides complex social service intervention to individuals, families and groups ranging from diagnostic assessment, short term counseling, crisis intervention, community resource referrals, client advocacy, support, outreach, follow-up and intra/inter agency consultations
• Provides education and training to introduce or improve coping skills of individuals and families
• Documents services rendered in clinical records
• Responsible for following the required assessment format to ensure all elements for effective discharging have been met with the ultimate goal of reducing readmissions
• Responsible for partnering with the multidisciplinary team to ensure financial resources have been assessed and a determination made to ensure there are limited placement barriers post discharge
• Conducts social service orientation for physician, nurses, and students as appropriate
• Utilizes problem-solving skills to identity and facilitate problem resolution in team functioning
• Participates in staff meetings and education programs for staff and community agencies as assigned
• Assumes responsibility for continuous professional self-development
• Alters activities/behaviors to reflect/ensure adequate care appropriate to the age of patients served (i.e. adolescent, geriatric, pediatric, neo-natal, adult) described in the area/unit age-specific and/or job specific competencies
• Collaborates with multi-disciplinary team members to facilitate the coordination and deliver) of services that assures appropriate treatment plans and continuity of care
• Initiates advocacy/liaison role for patients/clients in referrals to and from community agencies: collaborates with agency and hospital personnel in referral activities: cultivates referral resources
• Interprets impact on client functioning of environmental conditions and family interactions through home visits and outpatient encounters

Job Requirements

• Minimum of a Master's of Social Service or related field degree including but not limited to a MSW
• Active licensure as a Social Worker or Clinical Social Worker
• Social service experience in a healthcare setting dealing with pediatric, adolescent, adult and geriatric patients is preferred

Knowledge, Skills & Abilities

• Knowledge and skills necessary to provide care appropriate to the age of patients served. Must demonstrate knowledge of growth and development principles over the life span and possess the ability to assess data/interpret appropriate information needed to identify each patient's requirements relative to age-specific needs. Ability to use age appropriate communication and skills detailed in the department/area/unit job specific/age specific competencies
• Analytical, psychosocial assessment and counseling skills
• Knowledge of pertinent State/Federal laws and regulations, community systems and resources
• Ability to work cooperatively with multi-discipline teams in situations requiring a high degree of flexibility, creativity, initiative
• Ability to apply social service techniques/principles including evaluation, intervention, and case management
• Ability to perform duties independently under the direction of specified supervisor
• Ability to recognize own limitations and seek assistance from appropriate resources as needed

Accredited by The Joint Commission and named as one of Indiana’s best employers by Forbes magazine for two consecutive years and the top hospital in the state for community benefit by the Lown Institute , Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the first verified adult burn center in Indiana and Sandra Eskenazi Mental Health Center, the first community mental health center in Indiana, just to name a few.