Inpatient Social Worker: Discharge & Care Coordination

Advocate Health; Downers Grove (IL); On-site; USD 60,000 - 90,000; Full time

Job summary

Advocate Health is looking for an experienced hospital social worker to assess social needs, plan with patients and families, and drive safe discharge planning. You will collaborate with physicians, nurses, and case managers to arrange post-acute care and community resources while supporting CMS requirements.

Your role includes guiding families through advance directives, addressing barriers to discharge, and contributing to care continuity within an accountable care framework.

Qualifications

• Master’s degree in social work from a CSWE-accredited program.
• ILS/LSW eligibility in Illinois with preferred LCSW licensure.
• Experience in hospital social work and discharge planning recommended.
• Ability to work in a multidisciplinary team and communicate effectively.

Responsibilities

• Conducts psychosocial assessments, establishes appropriate plans, and initiates interventions with patient/family, aligned with discharge planning goals.
• Collaborates with the multidisciplinary team to coordinate post-acute placement, palliative/hospice services, equipment, home healthcare, and community resources.
• Performs utilization management activities including data collection, CMS updates, and coordination of denial management.
• Educates patients and families about Advance Directives and participates in related legal processes when needed.
• Maintains knowledge of regulations impacting care delivery and educates patients on community resources; facilitates timely discharge and transitions to post-acute care.

Skills

Social work principles

Time management

Communication & collaboration

Safety in healthcare (ACO)

Education

Master’s degree in Social Work (CSWE accredited)

LSW licensure eligibility (Illinois)

LCSW licensure preferred

Job description

Advocate Health is looking for an experienced hospital social worker to assess social needs, plan with patients and families, and drive safe discharge planning. You will collaborate with physicians, nurses, and case managers to arrange post-acute care and community resources while supporting CMS requirements.

Your role includes guiding families through advance directives, addressing barriers to discharge, and contributing to care continuity within an accountable care framework.