Hospital Care Transitions Social Worker

Boston Medical Center; Baltimore (MD); Sur place; USD 58 000 - 94 000; Plein temps

Résumé du poste

GBMC HealthCare is seeking a Social Worker in Continuing Care to assess psychosocial needs, plan discharge care, and coordinate with home health, rehab, and mental health services. You will work closely with physicians, nurses, and a multidisciplinary team to ensure smooth transitions and optimal patient outcomes.

The role requires a MSW and Maryland licensure (LMSW/LCSW) with 1–3 years in hospital settings, plus strong communication and counseling skills for diverse patient populations.

Qualifications

• Masters in Social Work or equivalent experience/certification.
• Licensed in Maryland as LMSW or LCSW.
• 1–3 years hospital or healthcare discharge planning experience.

Responsabilités

• Interview patients and families to assess psychosocial needs and develop discharge plans.
• Facilitate family meetings to identify needs and continue care plans.
• Educate patients and families about resources, rights, responsibilities, advance directives, end-of-life care, and insurance navigation.
• Coordinate complex care plans with home health, social services, rehab, and mental health providers.
• Advocate for patients to access needed resources and services.
• Collaborate with physicians, nurses, and the multidisciplinary team on care initiatives.

Connaissances

Interview skills

Assessment skills

Counseling

Motivational interviewing

Cultural competency

Multidisciplinary teamwork

Formation

Master's in Social Work

Equivalent experience or certification

Outils

Electronic medical records

Description du poste

GBMC HealthCare is seeking a Social Worker in Continuing Care to assess psychosocial needs, plan discharge care, and coordinate with home health, rehab, and mental health services. You will work closely with physicians, nurses, and a multidisciplinary team to ensure smooth transitions and optimal patient outcomes.

The role requires a MSW and Maryland licensure (LMSW/LCSW) with 1–3 years in hospital settings, plus strong communication and counseling skills for diverse patient populations.