Hospital Care Transition Specialist

Emory Healthcare; Atlanta (GA); On-site; USD 55,000 - 75,000; Full time

Job summary

Emory Healthcare is seeking a Social Work Care Manager I (WEO) to coordinate patient care from admission through discharge, ensuring smooth transitions and high-quality outcomes. You will collaborate with the interdisciplinary team to assess needs, identify post-acute services, and advocate for patients and families with internal and external stakeholders.

The role emphasizes timely referrals, complex care planning, and discharge coordination, aiming to balance clinical needs with payer

Qualifications

• Must have a Master of Social Work from an accredited institution.
• 1 year recent healthcare experience preferred, acute care setting preferred.
• ACM, CCM preferred.

Responsibilities

• Coordinate patient care from admission through discharge to ensure smooth transitions.
• Attend rounds, care conferences, and care team meetings as part of the interdisciplinary team.
• Identify and secure post-acute services and referrals in a timely manner.
• Educate patients and families about post-acute options, transitions, and readmission mitigation.
• Collaborate with payors and hospital to advocate for appropriate, covered services.
• Ensure discharge planning aligns with medical clearance date and projected length of stay.

Skills

Care coordination

Interdisciplinary teamwork

Education

Master of Social Work (MSW)

Tools

EMR systems

Job description

Emory Healthcare is seeking a Social Work Care Manager I (WEO) to coordinate patient care from admission through discharge, ensuring smooth transitions and high-quality outcomes. You will collaborate with the interdisciplinary team to assess needs, identify post-acute services, and advocate for patients and families with internal and external stakeholders.

The role emphasizes timely referrals, complex care planning, and discharge coordination, aiming to balance clinical needs with payer