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Augusta University in Georgia seeks a Social Worker Transition Coordinator at Gracewood Hospital to perform psychosocial assessments, develop action plans, and maintain data sheets. You will manage quarterly case notes, coordinate transitions, and liaise with families, clinics, and hospital staff to ensure compliant care and documentation.
Requirements include a Master's in Social Work and at least two years of related experience.
The incumbent will perform social work and transition coordinator duties at Gracewood Hospital. This includes but is not limited to psychosocial assessments, action plans, and data sheets; quarterly and monthly case management notes on individuals; contact notes; DMA-7s bi-monthly; liaison between family, outside clinics, and the Gracewood Hospital facility; purchasing and discarding of items for individuals as needed (furniture, clothing, electronics, medical devices, etc.); attend meetings as necessary and required; maintain legal documents and inform DBHDD legal of any guardianship changes; complete in‑service and all AU and DBHDD trainings as required by both organizations.
Assessments
Assessments completed 30‑45 days prior to annual IPP conference. Updates IPP in staffing folder, update action plans, and data sheet as needed in shared drive. Follow process for PPr: validate programs with QIDP and validation forms, update as needed for individuals on caseload. Update data sheet and action plans to reflect new programs needed.
Active Treatment
Interact/engage with individuals on their living area/dining room/activities; on/off campus events etc.
Training
In‑service (DBHDD and AU). Competency (DBHDD and AU)
Transition
Per DOJ, note family preference for community placement. Meeting with Office of Transition Mgr, Office of Crisis and Transition Service‑Poythress twice per month. Stout Documentation‑in Avatar and to the family by the 5th of the month.
Quarterly and Case Management Notes
Quarterly notes due no later than last day of the month. Transition notes due last day of the quarter. Case management notes due as individual meetings held, telephone calls with families, visits, change in function.
DMA‑7
Receive DMA‑7 (due on 1st and 15th of months); forward to appropriate nurse for individuals. SW then scans and forwards into chart for individual.
Follow up with representative regarding attempted and unsuccessful telephone calls from medical staff regarding incidents or consents. Contact representative/family/legal guardian for consent to purchase items and ID team recommends and completes acknowledgment forms. Assist representative/family/legal guardian with paperwork or other situations/issues they may not understand. Receive requests for visits from family/representative and email requests to security and staff involved in the individuals care. Update any change of address/phone number of representative and upcoming Psychosocial assessment. Assist ECRH clinic with connecting outside clinics/physician with representatives for consent/information.
Purchasing/Discarding
Based on individuals need and ID team meetings, purchase furniture/electronic for individuals on caseload (follow protocol for inventorying purchased items)
Final Notes
Death summary (in Avatar). Discharge Summary (in Avatar)
Skilled Unit Only (based on caseload assignment)
MDS book once a month (update Social Work portion). QAPI meeting for SNF once a month
Meetings
Leadership Meeting ECRH (once a month). Statewide Social Work DBHDD (once a month). Continued Habitation Gracewood (Every Monday). Human Rights DBHDD (once a month).
Legal Issues
Inform appropriate person if legal guardian deceases or there is a change in legal guardianship. Inform legal if there is no one to serve as representative for individual. If an individual has only one representative, alert legal. Assist Marshall's Office/Sheriff's Office with serving legal paperwork to individuals (wills and/or family estate issues)
Other
Other duties as assigned.
Educational Requirements
Master's Degree from an accredited college or university in Social work, Psychology, or relevant Social science field area and a minimum of 2 years of directly related experience.
Abilities
Ability to maintain confidentiality
Detail‑oriented
Excellent interpersonal, verbal, and written communication skills
Proficient in Microsoft Office and other computer software/databases
Shift: Days/M‑F (work outside of the normal business hours will likely be required of an employee in an exempt level position)
Pay Band: 11
Salary to be commensurate with qualifications of the selected candidate within the established range (generally minimum‑midpoint) of the position
Recruitment Period: 7/8/26 Until Filled
Benefits that may be elected could include health insurance, dental insurance, life insurance, Teachers Retirement System (or Optional Retirement Plan), as well as earned vacation time, sick leave, and 13 paid holidays.
Experienced full‑time employees who have been employed with us successfully for more than 6 months may be considered for the Tuition Assistance Program.
All selected candidates are required to successfully pass a Background Check review prior to starting with Augusta University.
If applicable for the specific position based on the duties: the candidate will also need to have a credit check completed for Positions of Trust and or approved departmental Purchase Card usage.
Motor vehicle reports are required for positions that are required to drive an Augusta University vehicle.
For Faculty Hires: Final candidates will be required to provide proof of completed academic degree(s) as well as post‑secondary coursework in the form of original transcript(s). Those candidates trained by a foreign institution will also be required to provide an educational/credential evaluation.
All employees are responsible for ensuring the confidentiality, availability, and integrity of sensitive [patient, student, employee, financial, business, etc.] information by exercising sound judgment and adhering to cybersecurity and privacy policies during their employment and beyond.
Augusta University is proud to be an equal opportunity employer welcoming applicants from underrepresented groups, including individuals with disabilities and veterans.