MSW Social Worker — Transition & Care Manager

Carson Tahoe Health; Carson City (NV); On-site; USD 70,000 - 85,000; Full time

Job summary

Carson Tahoe Health in Carson City, NV is seeking a Nursing Support professional in full-time day shift to support case management and transition of care. You will assess needs, coordinate resources and ensure safe discharges while promoting patient self-determination.

The role emphasizes psycho-social assessments, throughput optimization and preventing readmissions, with a strong focus on social and post-acute services.

Qualifications

• This position requires a Master in Social Work from an accredited school.
• Excellent interpersonal, written and verbal communication skills.
• Demonstrated organizational, critical thinking and problem solving abilities.
• Unrestricted licensure in Nevada as LSW, LMSW, or LCSW.

Responsibilities

• Transition management: complete initial/comprehensive assessment within 24 hours of admission and plan discharge.
• Provide psycho-social assessment and interventions for patients with behavioral health issues, lack of social support, financial barriers, end of life, and adherence to plan.
• Ensure care plans and interventions are communicated to the health care team, patient/family, and post-acute providers.
• Complete timely, accurate documentation in the Electronic Medical Record.
• Care coordination: screen high risk patients for psycho-social issues and barriers; assist with cases and report to external agencies as required.
• Education: educate patient/family on discharge plan and train medical/nursing staff on transition issues; precept new staff.
• Compliance: ensure adherence to local/state/federal regulations and accreditation; operate within social work scope; participate in quality initiatives.
• Complex case management: perform assessments and reassessments per guidelines; escalate barriers; complete post-acute referrals within 3 days; schedule weekly family conferences.

Skills

Interpersonal skills

Written communication

Verbal communication

Organizational skills

Critical thinking

Problem solving

Computer literacy

Education

Master of Social Work (MSW)

Licensed Social Worker (LSW)

Licensed Masters Social Worker (LMSW)

Licensed Clinical Social Worker (LCSW)

Tools

Electronic Medical Record (EMR)

Job description

Carson Tahoe Health in Carson City, NV is seeking a Nursing Support professional in full-time day shift to support case management and transition of care. You will assess needs, coordinate resources and ensure safe discharges while promoting patient self-determination.

The role emphasizes psycho-social assessments, throughput optimization and preventing readmissions, with a strong focus on social and post-acute services.