Social Work Specialist - Discharge & Care Coordination

SUNY Downstate Medical Center; New York (NY); On-site; USD 65,000 - 95,000; Full time

Job summary

The Department of Social Work at SUNY Downstate Health Sciences University seeks a full-time TH Social Worker III to join its multidisciplinary team in providing psychosocial services to patients, families, and caregivers. The role assesses needs, develops interventions, and supports discharge planning across inpatient, outpatient, emergency, pediatric, and other settings.

Responsibilities include crisis intervention, advocacy, and community referrals, with collaboration among physicians,

Responsibilities

• Conduct psychosocial assessments of patients and families to identify emotional, behavioral, social, financial, and environmental factors affecting health, treatment, recovery, and discharge planning.
• Develop, implement, and evaluate individualized psychosocial intervention plans in collaboration with patients, families, caregivers, and the interdisciplinary healthcare team.
• Provide supportive counseling, crisis intervention, grief and bereavement support, and appropriate psychosocial interventions within the scope of professional licensure and supervision.
• Participate in interdisciplinary rounds, multidisciplinary huddles, case conferences, and care planning meetings to address psychosocial concerns and discharge needs.
• Collaborate with physicians, nurses, case managers, rehabilitation professionals, and other healthcare providers to facilitate coordinated, patient-centered care.
• Assist with safe, appropriate, and timely discharge plans, including coordination of home care, durable medical equipment (DME), community services, and post-acute care placements.
• Coordinate with Care Management and external agencies on referrals and placements to skilled nursing facilities, subacute rehabilitation, long-term care, and other appropriate settings.
• Identify psychosocial barriers that may contribute to avoidable admissions, prolonged length of stay, delayed discharge, or preventable readmissions; collaborate with the team to address them.
• Educate and advocate for patients and families regarding treatment-related needs, financial assistance, public benefits, healthcare coverage, and community support programs.
• Assist patients and families in accessing appropriate Medicare, Medicaid, federal, state, and community resources.
• Assess and respond to suspected child abuse, elder abuse, neglect, domestic violence, and other vulnerable patient situations; complete required reporting and referrals in accordance with law and hospital policy.
• Coordinate, as appropriate, with the Administration for Children’s Services (ACS), Adult Protective Services (APS), and other community agencies.
• Facilitate patient and family conferences to address psychosocial concerns, treatment decisions, discharge planning, and continuity-of-care needs.
• Assist with guardianship referrals in collaboration with Risk Management, Legal Affairs, and other appropriate departments.
• Provide psychosocial assessment, crisis intervention, and discharge planning support in emergency and other assigned clinical settings.
• Provide age-appropriate psychosocial support and care coordination for pediatric, adolescent, adult, and geriatric populations, as applicable to the assigned service.
• Document assessments, interventions, referrals, and care coordination accurately, promptly, and confidentially in the electronic medical record; complete case closure within departmental timeframes.
• Support organizational goals for effective transitions of care, appropriate utilization of resources, and length-of-stay management through interdisciplinary collaboration.
• Participate in professional development, departmental meetings, in-service education, and quality improvement initiatives.
• Comply with applicable federal and state regulations, professional standards, accreditation requirements, and hospital policies.
• Perform other duties as assigned, consistent with professional licensure, qualifications, and institutional needs.

Job description

The Department of Social Work at SUNY Downstate Health Sciences University seeks a full-time TH Social Worker III to join its multidisciplinary team in providing psychosocial services to patients, families, and caregivers. The role assesses needs, develops interventions, and supports discharge planning across inpatient, outpatient, emergency, pediatric, and other settings.

Responsibilities include crisis intervention, advocacy, and community referrals, with collaboration among physicians,