LCSW - Transitional Care Impact & Growth

VNS Health; Buffalo (NY); On-site; USD 83,000 - 124,000; Full time

Benefits offered by this job

Professional growth

CEU credits

Internal mobility

Job summary

VNS Health is seeking a per visit Transitional Care Social Worker to deliver psychosocial services after hospital discharge. You will collaborate with the care team to assess needs, plan interventions, and coordinate community resources, ensuring smooth transitions for high-risk patients.

The role requires LCSW licensure in New York, potential for a valid driver’s license, and use of EMR for documentation. A focus on reducing readmissions and strong teamwork is essential.

Qualifications

• Current registration to practice as a Licensed Clinical Social Worker (LCSW) in New York State required.
• National Provider Identifier (NPI) number required or must be obtained upon hire.
• Valid driver's license as determined by operational/regional needs may be required

Responsibilities

• Collaborates with the transitional care team to reduce preventable hospitalizations.
• Makes home visits and develops a plan for the transitional care episode.
• Performs weekly or more frequent phone visits for assessment, monitoring and education.
• Provides psychosocial work services including counseling and resource planning.
• Maintains documentation in electronic medical records and reports outcomes.
• Assists in discharge planning and coordinates with the care team.

Skills

LCSW

Bilingual

Education

Master's Degree in Social Work

Job description

VNS Health is seeking a per visit Transitional Care Social Worker to deliver psychosocial services after hospital discharge. You will collaborate with the care team to assess needs, plan interventions, and coordinate community resources, ensuring smooth transitions for high-risk patients.

The role requires LCSW licensure in New York, potential for a valid driver’s license, and use of EMR for documentation. A focus on reducing readmissions and strong teamwork is essential.