Discharge Planning Social Worker: Care Transitions

Athol Hospital; Athol (MA); On-site; USD 52,000 - 83,000; Full time

Job summary

Athol Hospital in Athol, MA, is seeking a Social Worker to support discharge planning and care transitions, conducting psychosocial assessments and coordinating post-acute care. The role emphasizes timely documentation and multidisciplinary collaboration to ensure patient-centered transitions.

Responsibilities include patient and family education, barrier assessment, and coordination with care teams to optimize outcomes. A 40-hour, day-shift schedule and competitive compensation are provided.

Qualifications

• Associates degree required; bachelor's preferred in SW or related field.
• Minimum 1–3 years in hospital, SNF, or community health setting.
• Licensure: MA State LCSW/LSW/LSWA or equivalent.

Responsibilities

• Care Transitions & Coordination reporting to Care Transitions Manager.
• Discharge planning and coordination for appropriate post-acute care; multidisciplinary collaboration.
• Conduct psychosocial assessments and identify barriers to care.
• Complete assessments and documentation within regulatory standards and timeframes.
• Provide education to patients and families about care plans and resources.
• Collaborate with teams to support discharge planning and continuity of care.

Skills

Independent work

Team collaboration

Verbal and written communication

Evidence-based assessment

Crisis intervention

Education

Associates degree

Bachelor's degree in Social Work or related field

Tools

Computerized data collection

Report writing

Quality monitoring

Job description

Athol Hospital in Athol, MA, is seeking a Social Worker to support discharge planning and care transitions, conducting psychosocial assessments and coordinating post-acute care. The role emphasizes timely documentation and multidisciplinary collaboration to ensure patient-centered transitions.

Responsibilities include patient and family education, barrier assessment, and coordination with care teams to optimize outcomes. A 40-hour, day-shift schedule and competitive compensation are provided.