Hospital Social Worker: Care Transitions & Resources

Kaiser Permanente; Wailuku (HI); On-site; USD 54,000 - 68,000; Full time

Job summary

Kaiser Permanente Maui Memorial is seeking a social worker to provide psychosocial assessments, discharge planning, and care coordination for patients and families. The role serves as a liaison between Maui Health System and community agencies to integrate services and improve outcomes.

Responsibilities include crisis intervention, family meetings, resource navigation, and advocacy for patient rights, while ensuring CMS and HIPAA compliance and contributing to interdisciplinary rounds.

Qualifications

• Healthcare experience in social work settings.
• Ability to network with community agencies and resources.
• Strong communication and interpersonal skills.

Responsibilities

• Conduct psychosocial assessments to identify patient and family needs related to hospitalization and discharge planning.
• Develop and implement social work service plans focused on resource needs and care transitions.
• Coordinate discharge planning and care transitions, including referrals to appropriate providers.
• Manage socially complex cases involving barriers to discharge such as homelessness or guardianship.
• Collaborate with community agencies and legal resources to address social determinants of health.
• Provide crisis intervention and emotional support during medical events or end-of-life situations.
• Facilitate family meetings to clarify goals of care and address psychosocial concerns.
• Perform case management and resource navigation, including financial assistance and transportation.
• Advocate for patient rights and assist with advance directives.
• Ensure CMS and HIPAA compliance; participate in rounds and care conferences.
• Provide culturally competent care and respect diversity.
• Document per departmental standards and participate in performance improvement.
• Attend departmental meetings and assist with orientation of new personnel.

Skills

Healthcare experience

Community agency networking

Communication skills

Education

Bachelor's Degree in Social Work with 2 years healthcare experience

Master's Degree in Social Work

Job description

Kaiser Permanente Maui Memorial is seeking a social worker to provide psychosocial assessments, discharge planning, and care coordination for patients and families. The role serves as a liaison between Maui Health System and community agencies to integrate services and improve outcomes.

Responsibilities include crisis intervention, family meetings, resource navigation, and advocacy for patient rights, while ensuring CMS and HIPAA compliance and contributing to interdisciplinary rounds.