Social Worker

Nexus Health Systems; Shenandoah (DE); On-site; USD 52,000 - 75,000; Full time

Job summary

The Social Worker Case Manager at Nexus Children’s Hospital – Shenandoah collaborates with an interdisciplinary team to ensure safe discharge planning, psychosocial assessment, and family advocacy from admission to discharge.

You will coordinate resources, document progress, and support families through medical and behavioral health needs, with a Bachelor’s in Social Work and at least two years of hospital experience.

Qualifications

• Bachelor’s degree in Social Work is required.
• Master’s degree in Social Work is preferred.
• Active Texas Social Work license required.

Responsibilities

• Complete social service screening, psychosocial assessment, and discharge planning within 72 hours.
• Develop a social services plan of care and integrate it into the interdisciplinary care plan.
• Update care plans weekly during team conference.
• Identify patients and families needing counseling and provide support with empathy.
• Facilitate communication between families and the treatment team.
• Coordinate family conferences with case managers and physicians during admission and discharge planning.
• Document progress, barriers, and interventions in the medical record thoroughly.

Education

Bachelor’s degree in Social Work

Master’s degree in Social Work

Job description

Social Worker

Facility:

Nexus Children’s Hospital – Shenandoah

About Nexus Children’s Hospital – Shenandoah

Nexus Children’s Hospital – Shenandoah is a 50-bed specialty inpatient hospital providing advanced, structured care for children and adults with complex medical and behavioral health needs. Our campus includes a 16-bed ICU/Medical-Surgical Unit for high-acuity medical care and a 34-bed Medical-Behavioral Unit supporting patients with co-occurring medical and psychiatric conditions.

We specialize in treating brain and spinal cord injuries, chronic illnesses, neurobehavioral disorders, and adolescents with complex co-occurring diagnoses. At Nexus Health Systems, we are bridging medical and behavioral care so no patient falls through the cracks. Our programs deliver compassionate, specialty-driven treatment that helps individuals heal, grow, and achieve long-term success — because at Nexus, we’re mending minds.

Position Summary

The Social Worker Case Manager is a vital member of the interdisciplinary team, supporting patients and families from admission through discharge. This role focuses on safe, effective discharge planning, psychosocial assessment, patient/family advocacy, and strengthening communication between families and clinical teams. The Social Worker helps families navigate stressors, understand the care process, and access needed community resources — ensuring each patient transitions safely and smoothly back into their community.

Key Responsibilities

Clinical & Assessment

• Complete social service screening, psychosocial assessment, and discharge planning assessment for each admission/readmission within 72 hours.
• Ensure assessments include all required policy elements and are documented clearly in the medical record.
• Develop a social services plan of care and integrate it into the interdisciplinary care plan.
• Update care plans weekly during team conference.

Family Support & Counseling

• Identify patients and families in need of counseling and provide support with warmth, empathy, and professionalism.
• Help patients and families focus on and resolve psychosocial issues affecting their hospital experience.
• Act as a patient/family advocate during care plan discussions and conferences.

Communication & Coordination

• Facilitate effective communication between families and the interdisciplinary treatment team.
• Coordinate family conferences with case managers and physicians during admission and discharge planning.
• Work collaboratively with clinical staff to support required family education before discharge.
• Communicate team recommendations and level-of-care needs to families after each treatment conference.

Discharge Planning

• Identify and document discharge barriers and collaborate with the team to resolve them early.
• Maintain care provider relationships and locate appropriate community resources for post-discharge needs.
• Provide verbal and written referrals to patients and families.
• Initiate early communication with CPS when discharge barriers present significant safety or care concerns.

Documentation & Compliance

• Document progress, barriers, and interventions in the medical record thoroughly and timely.
• Maintain communication with staff members regarding updates in patient care.
• Perform other duties as assigned to support patient care and hospital operations.

Qualifications

Education

• Bachelor’s degree in Social Work required
• Master’s degree in Social Work preferred

Experience

• Minimum of 2 years of experience as a Social Worker or Case Manager
• Experience in a medical setting preferred

Licensure/Certification

• Active Texas Social Work license required