Hospital Social Worker: Discharge & Care Coordination

AdventHealth; Orlando (FL); On-site; USD 36,000 - 67,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

Paid Time Off

403(b) Retirement Plan

Parental Leave

Career Development

Well-being Resources

Mental Health Support

Pet Benefits

Job summary

AdventHealth in Orlando, FL seeks a licensed Master’s in Social Work to support discharge planning, care coordination, and patient advocacy across inpatient and emergency settings.

Responsibilities include assessing readmissions, organizing multi-disciplinary conferences, documenting plans, communicating with payors, and providing grief counseling when needed. 4+ years of social work experience required; Florida Level 2 background screening, ACM/CCM preferred.

Qualifications

• Master's in Social Work (MSW) required.
• 4+ years experience in social work
• Experience in Care Management preferred

Responsibilities

• Communicates with and educates patients and families regarding emotional, social, and financial impacts of illness and mobilizes family/community resources to meet identified needs while advocating for patient and family empowerment in making health care decisions and accessing needed services.
• Assesses readmitted patients for the patient’s and family’s perceived reasons for the readmission.
• Organizes and facilitates patient and family care conferences with the multidisciplinary team.
• Documents discharge planning evaluation, ongoing assessment, discharge plans, MDRs, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
• Provides patient and family advocacy, and support patient’s choice and patient rights during hospitalization.
• Communicates with Payors patient’s needs for authorization for post-acute care as needed.
• Provides grief counseling, disease adjustment support, crisis intervention, goals of care planning support, and de‑escalation services for patients as appropriate.
• Assesses patients’ and families’ wholistically for discharge planning needs in the inpatient, observation and/or emergency departments, including prior functioning, support systems, financial, and psychosocial in a timely fashion to avoid delays in discharge planning.
• Reviews the medical record, including medications, history and physical, labs, and progress notes and incorporates the clinical, social, and financial factors into the transition of care plan.
• Develops discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, making arrangements for post-acute care services and facilities as well as community care for social needs.
• Leverages technology and follows standard work and best practices to communicate with post-acute care services and facilities to ensure patient care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
• Actively participates in multi-disciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for all assigned patients to identify resources necessary at discharge and ensure a timely transition, escalating care delays to leadership as appropriate.
• Other duties as assigned.

Skills

Interpersonal communication

Psychosocial assessment

Customer service

Discharge planning

Education

Master's in Social Work

Tools

Microsoft Word

Outlook

Job description

AdventHealth in Orlando, FL seeks a licensed Master’s in Social Work to support discharge planning, care coordination, and patient advocacy across inpatient and emergency settings.

Responsibilities include assessing readmissions, organizing multi-disciplinary conferences, documenting plans, communicating with payors, and providing grief counseling when needed. 4+ years of social work experience required; Florida Level 2 background screening, ACM/CCM preferred.