Field Social Worker: Care Coordination & Discharges

Your Health Organization; United States; On-site; USD 52,000 - 78,000; Full time

Benefits offered by this job

Competitive pay

401K match

HDHP insurance with prescrip services

HSA generous PTO

Mileage reimbursement

Career development

Job summary

Your Health is seeking a qualified Social Worker to support patients across Savannah-area facilities and homes. The role requires reliable transportation as daily travel is required, with 8-hour shifts from Monday to Friday.

You will perform advanced care planning, cognitive assessments, placement decisions, and resource coordination, building relationships with referral sources, families, and care teams. This full-time position offers a competitive compensation package with growth opportunities

Qualifications

• Must be a licensed Social Worker with strong case management skills.
• Ability to travel daily to homes and facilities.

Responsibilities

• Initiate Advance Care Planning for patients throughout assigned Care Team including facilities.
• Complete Daily Comprehensive Assessments on patients.
• Complete Daily Care Plans on patients.
• Document Chronic Care Management time daily.
• Meet Daily Productivity Goals.
• Coordinate discharges at contracted facilities.
• Coordinate Placement.
• Continuation of coverage e.g., coordinating acute visits for falls and med changes.
• Build and maintain professional relationships with referral sources.
• Maintain strong communication between referral sources, patients, families and Care Teams.

Skills

Social Work

Job description

Your Health is seeking a qualified Social Worker to support patients across Savannah-area facilities and homes. The role requires reliable transportation as daily travel is required, with 8-hour shifts from Monday to Friday.

You will perform advanced care planning, cognitive assessments, placement decisions, and resource coordination, building relationships with referral sources, families, and care teams. This full-time position offers a competitive compensation package with growth opportunities