Senior Care Coordination Social Worker - Discharge & Transitions

3110 Kennestone Hospital, Inc.; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

Wellstar Health System seeks a Care Coordination Social Worker Senior to assess psychosocial needs and coordinate care across the continuum, ensuring timely, safe discharge plans aligned with patient goals.

The SW Sr acts as a resource for complex cases, mentoring staff, and partnering with RNs and physicians to address social determinants of health, engage families, and streamline transitions within the care team.

Qualifications

• Bachelor's or Master's in Social Work required; MSW preferred.
• Experience coordinating social work discharge planning and care transitions.
• Ability to identify barriers to timely disposition and navigate resources.

Responsibilities

• Complex Disposition Planning: implement discharge plans and provide timely resources.
• Identify and document barriers to timely disposition for patients.
• Participate in Interdisciplinary Rounds to align discharge plans with care needs.
• Initiate post-acute referrals to ensure safe transition to next level of care.
• Mentor and precept new social work staff and students when needed.
• Document psychosocial assessments and care plans in the medical record.

Skills

Psychosocial assessment

Discharge planning

Care coordination

Interdisciplinary collaboration

Mentoring/leadership

Education

Bachelor's in Social Work

MSW preferred

Job description

Wellstar Health System seeks a Care Coordination Social Worker Senior to assess psychosocial needs and coordinate care across the continuum, ensuring timely, safe discharge plans aligned with patient goals.

The SW Sr acts as a resource for complex cases, mentoring staff, and partnering with RNs and physicians to address social determinants of health, engage families, and streamline transitions within the care team.