PD Social Worker

RWJBarnabas Health; Jersey City (NJ); On-site; USD 57,000 - 82,000; Part time

Job summary

RWJBarnabas Health seeks a Social Work Case Manager to provide direct clinical social work and case management for patients and families in Jersey City. The role involves psychosocial assessments, care planning, discharge coordination, and collaboration with physicians, nurses, and post-acute providers.

Responsibilities include ensuring regulatory compliance, addressing social determinants of health, and supporting transitions across care settings.

Qualifications

• MSW degree required and state licensure as LSW/LCSW in New Jersey.
• Experience in clinical social work, discharge planning, and care coordination in hospital settings is expected.
• Understanding of CMS Conditions of Participation, HIPAA, and Medicare requirements is preferred.

Responsibilities

• Conduct comprehensive psychosocial assessments and document patient needs, risk factors, and discharge requirements.
• Develop and implement individualized clinical social work interventions and discharge plans.
• Coordinate referrals for post-acute care services and collaborate with interdisciplinary teams.

Skills

Clinical social work

Care coordination

Discharge planning

Interdisciplinary teamwork

Patient advocacy

Education

MSW (Master of Social Work)

NJ LSW/LCSW licensure

ACM/CCM certification (preferred)

Tools

Electronic Health Records (EHR)

Electronic referral platforms

Job description

Pay Transparency The above reflects the anticipated hourly wage range for this position if hired to work in New Jersey. Req #: 0000272260. Category: Behavioral and Mental Health. Status: Per Diem. Shift: Day. Facility: Jersey City Medical Center. Department: Case Management. Pay Range: $50.44 per hour. Location: 355 Grand Street, Jersey City, NJ 07302. Job Title: PD Social Worker. Department Name: Case Management. Req #: 0000272260. Status: Hourly. Shift: Day. Pay Range: $50.44 - $50.44 per hour.

Social Work Case Manager

The Social Work Case Manager provides direct clinical social work and case management services to patients and their families through an interdisciplinary team approach. This role is responsible for conducting comprehensive psychosocial assessments, developing individualized care plans, coordinating safe and effective patient discharges, facilitating transitions of care, and addressing healthcare-related social needs. The Social Work Case Manager serves as a key liaison between patients, families, physicians, nurses, utilization review personnel, post-acute care providers, and community resources to promote continuity of care and positive patient outcomes. This role requires a strong understanding of hospital case management practices, including discharge planning, patient flow, length of stay (LOS) management, utilization management, healthcare reimbursement, regulatory compliance, and social determinants of health (SDOH). The Social Work Case Manager actively participates in interdisciplinary rounds and quality improvement initiatives to support organizational goals, improve operational performance, reduce avoidable delays and readmissions, and ensure safe, patient-centered care.

Key Responsibilities May Include

• Conducting comprehensive psychosocial assessments and documenting patient needs, risk factors, support systems, barriers to care, and discharge requirements within the electronic health record (EHR).
• Developing and implementing individualized clinical social work interventions and discharge plans to promote safe transitions of care, reduce readmissions, and support continuity of care across acute, post-acute, and community settings.
• Participating in interdisciplinary rounds (IDR), collaborating with physicians, nurses, utilization review personnel, and other healthcare professionals to communicate patient needs, provide discharge planning updates, and coordinate appropriate interventions.
• Utilizing health risk assessments and Social Determinants of Health (SDOH) screenings to identify patients with healthcare-related social needs and coordinate referrals to appropriate community resources and support services.
• Coordinating timely referrals for post-acute care services, including durable medical equipment (DME), home health services, rehabilitation, skilled nursing facilities, and other appropriate care settings through electronic referral systems.
• Ensuring compliance with applicable regulatory requirements, including CMS Conditions of Participation, HIPAA, patient rights, Medicare Beneficiary Notices, and organizational policies and procedures.
• Collaborating with the Utilization Review team to support insurance authorization, medical necessity reviews, clinical documentation requirements, and appropriate patient level-of-care determinations.
• Applying working knowledge of utilization management principles, healthcare reimbursement models, and healthcare financing, including Medicare fee-for-service, managed care, bundled payments, value-based arrangements, and other payment structures.
• Proactively managing patient flow by identifying discharge barriers, addressing complex psychosocial and operational challenges, escalating unresolved issues to appropriate leadership, and supporting initiatives to improve throughput and reduce length of stay.
• Providing clinical social work interventions, including supportive counseling, crisis intervention, and evidence-based psychotherapeutic approaches to address psychosocial distress related to illness, trauma, grief and loss, major life transitions, and end-of-life concerns.
• Conducting specialized psychosocial assessments, when indicated, for patients receiving hemodialysis, transplant services, perinatal care, oncologic treatment, and other specialized medical services.
• Supporting patients and families in navigating the emotional, interpersonal, and practical challenges associated with serious illness, survivorship, changes in family dynamics, altered social roles, and transitions in care.
• Facilitating difficult conversations involving discharge planning disputes, family dynamics, adjustment to illness, resource limitations, and other circumstances that may affect patient care and discharge outcomes.
• Coordinating services across the healthcare continuum by engaging post-acute providers, community agencies, insurance representatives, and other external partners to address patient needs and promote successful transitions.
• Participating in professional development, departmental initiatives, and quality improvement activities focused on reducing length of stay, improving patient throughput, enhancing care coordination, and supporting organizational performance goals.
• Maintaining accurate, timely, and comprehensive clinical documentation, referral records, discharge plans, and other case management information in accordance with regulatory, legal, and organizational requirements.
• Demonstrating professionalism, cultural sensitivity, compassion, and sound clinical judgment when engaging diverse patient populations and their families.
• Undertaking additional responsibilities, assignments, and departmental initiatives as directed by department leadership.

This Role Might Be For You If

• You are passionate about advocating for patients and families while improving healthcare outcomes through effective clinical social work, care coordination, and discharge planning.
• You have the ability to conduct comprehensive psychosocial assessments, identify barriers to care, and develop individualized, patient-centered interventions.
• You understand the importance of safe discharge planning, continuity of care, and coordination across acute, post-acute, and community healthcare settings.
• You excel at collaborating with physicians, nurses, utilization review personnel, and other interdisciplinary team members to facilitate effective care planning and patient transitions.
• You possess strong analytical, organizational, and problem-solving skills and can navigate complex patient situations while balancing competing priorities in a fast-paced hospital environment.
• You understand healthcare reimbursement, utilization management, medical necessity criteria, insurance authorization, and the operational factors that influence patient flow and length of stay.
• You have knowledge of social determinants of health and can connect patients and families with appropriate community resources, support services, and post-acute care providers.
• You demonstrate strong clinical social work skills, including supportive counseling, crisis intervention, psychosocial assessment, and evidence-based interventions addressing illness, grief, trauma, and major life transitions.
• You are comfortable managing difficult conversations, navigating family dynamics, and addressing psychosocial challenges that may affect treatment decisions, discharge planning, and continuity of care.
• You demonstrate cultural sensitivity, empathy, and respect when working with diverse patient populations and their families.
• You are proficient in using electronic health records, electronic referral platforms, and care coordination tools to support clinical documentation, discharge planning, and patient transitions.
• You understand applicable healthcare regulations, including CMS Conditions of Participation, HIPAA, patient rights, and Medicare Beneficiary Notice requirements.
• You are adaptable, accountable, and capable of managing multiple patients, deadlines, and discharge planning responsibilities while maintaining accuracy and professionalism.
• You are committed to continuous professional development, quality improvement, patient advocacy, and organizational initiatives that promote operational efficiency and high-quality patient care.

Qualifications

• Master of Social Work (MSW) degree required.
• Current state licensure through the New Jersey State Board of Social Work Examiners as a Licensed Social Worker (LSW) or Licensed Clinical Social Worker (LCSW) required.
• EARC certification required within six months of hire, with certification arrangements coordinated by RWJBH.
• At least two years of post-licensure experience in a healthcare setting preferred, including acute care, home health, post-acute services, or related healthcare environments.
• Certification in Case Management (ACM or CCM) preferred.
• Demonstrated knowledge of clinical social work practices, psychosocial assessment, supportive counseling, crisis intervention, and evidence-based therapeutic approaches.
• Thorough understanding of hospital case management responsibilities, including discharge planning, transitions of care, interdisciplinary rounds, patient flow, and length of stay management.
• Knowledge of healthcare reimbursement models, including Medicare fee-for-service, managed care, bundled payments, value-based arrangements, and capitated payment structures.
• Understanding of utilization management principles, medical necessity criteria, insurance authorization processes, and appropriate level-of-care determinations.
• Knowledge of Social Determinants of Health (SDOH) and the ability to identify healthcare-related social needs and coordinate appropriate community-based resources and referrals.
• Demonstrated ability to conduct comprehensive assessments, identify complex psychosocial and discharge barriers, and develop effective, individualized care plans.
• Ability to coordinate referrals and transitions across acute, post-acute, and community-based healthcare settings, including home health, durable medical equipment, rehabilitation, and facility placement.
• Proficiency in electronic health records, electronic referral platforms, and care coordination systems, with the ability to maintain accurate, timely, and compliant clinical documentation.
• Knowledge of applicable regulatory, legal, and compliance requirements, including CMS Conditions of Participation, HIPAA, patient rights, and Medicare Beneficiary Notice requirements.
• Strong oral and written communication skills, with the ability to collaborate effectively with physicians, nurses, patients, families, insurance representatives, community agencies, and interdisciplinary healthcare teams.
• Demonstrated ability to manage difficult conversations, navigate complex family dynamics, and provide appropriate psychosocial support during illness, grief, trauma, and major life transitions.
• Strong clinical judgment, critical thinking, organizational, prioritization, and problem-solving skills, with the ability to manage competing priorities and a demanding caseload.
• Demonstrated professionalism, cultural sensitivity, compassion, flexibility, and the ability to work independently while contributing effectively to an interdisciplinary team.
• Commitment to patient advocacy, safe transitions of care, regulatory compliance, operational efficiency, quality improvement, and organizational policies and procedures.
• Ability to participate in additional departmental responsibilities, professional development activities, and special assignments as directed by department leadership.

RWJBarnabas Health is an Equal Opportunity Employer