Senior Care Transition & Discharge Social Worker

Wellstar Health System; Marietta (GA); On-site; USD 65,000 - 90,000; Full time

Job summary

Wellstar Health System in Georgia seeks a senior Care Coordination Social Worker to assess transitional care needs, coordinate across the continuum, and guide patients and families through discharge planning. The role includes expert consultation on psychosocial and resource needs, with emphasis on end-of-life planning and coordinated care transitions.

The SW Sr will mentor staff, participate in precepting new hires, and collaborate with RN Care Coordinators to address social determinants of

Qualifications

• Excellent written and verbal communication skills.
• Ability to work with diverse populations and families.
• Strong assessment, interview, and problem-solving capabilities.
• Knowledge of local, state, and federal regulations affecting discharge planning.

Responsibilities

• Implements discharge planning and provides timely resource information for complex patients.
• Identifies and documents barriers to timely disposition.
• Participates in Interdisciplinary Rounds to confirm discharge date and optimal care transition.
• Initiates post-acute referrals to ensure smooth transitions to next level of care.
• Assesses insurance coverage needs with PAS, financial counselor, or UM nurse.
• Mentors new social workers and participates in orientation and training.

Skills

Communication skills

Interdisciplinary collaboration

Assessment & interview

Regulatory knowledge

Resource coordination

Advocacy for patients/families

Education

Bachelor's Social Work

Master's Social Work

Job description

Wellstar Health System in Georgia seeks a senior Care Coordination Social Worker to assess transitional care needs, coordinate across the continuum, and guide patients and families through discharge planning. The role includes expert consultation on psychosocial and resource needs, with emphasis on end-of-life planning and coordinated care transitions.

The SW Sr will mentor staff, participate in precepting new hires, and collaborate with RN Care Coordinators to address social determinants of