Field Social Worker: Care Coordination & Discharge

Your Health Organization; Pooler (GA); On-site; USD 52,000 - 72,000; Full time

Benefits offered by this job

Competitive Compensation Package with

Employer Matched 401K

Free Visit & Prescriptive Services

Employer Matched HSA

Generous PTO Package

Job summary

Your Health Organization in Savannah area seeks a qualified Social Worker to assist our patients across multiple facilities and homes. This full-time role involves visiting patients in their homes and facilities, coordinating care and ensuring compassionate service daily.

The Social Worker will perform advance care planning, cognitive assessments, and discharge coordination, requiring reliable transportation for daily travel.

Qualifications

• Experience delivering patient-focused care.
• Ability to build relationships with referral sources and care teams.
• Strong communication and customer service skills.

Responsibilities

• Initiating Advance Care Planning for patients throughout their assigned Care Team (including facilities).
• Completing Daily Comprehensive Assessments on patients.
• Completing Daily Care Plans on patients.
• Documenting Chronic Care Management time daily.
• Meeting Daily Productivity Goals.
• Coordinating discharges at contracted facilities.
• Coordinating Placement.
• Continuation of coverage (acute visits for falls, med changes, etc.).
• Build and maintain professional relationships with referral sources.
• Maintain strong communication with patients, families, and Care Teams.

Skills

Empathy

Excellent communication

Home visits

Job description

Your Health Organization in Savannah area seeks a qualified Social Worker to assist our patients across multiple facilities and homes. This full-time role involves visiting patients in their homes and facilities, coordinating care and ensuring compassionate service daily.

The Social Worker will perform advance care planning, cognitive assessments, and discharge coordination, requiring reliable transportation for daily travel.