Social Worker II — Care Coordination & Discharge

Atrium Health Enterprise; Winston-Salem (NC); On-site; USD 55,000 - 75,000; Full time

Job summary

Atrium Health Wake Forest Baptist in North Carolina is seeking a Social Worker II to provide social work services, complex discharge planning and care coordination for patients and families. You will identify community resources, refer patients, and communicate psychosocial issues to the care team to support safe transitions.

The role emphasizes collaboration with a multi-disciplinary team to improve patient outcomes, perform psychosocial assessments, develop and monitor care plans, and advocate

Qualifications

• MSW from CSWE-accredited program.
• Healthcare setting experience preferred.
• Clinical licensure or provisional licensure preferred.
• ACM-SW certification preferred.

Responsibilities

• Identify patients who may benefit from case management through discharge planning and care coordination.
• Complete psychosocial assessments to evaluate emotional, social, environmental, and financial needs.
• Develop, implement, and monitor individualized psychosocial treatment plans.
• Provide crisis intervention, counseling, family counseling, grief support, and other social work interventions.
• Coordinate internal and external referrals to community resources and support services.
• Advocate for patients and families to address unmet needs and remove barriers to care.
• Collaborate with physicians, nurses, and interdisciplinary team members to support patient progression and discharge planning.
• Coordinate and facilitate patient and family care conferences as needed.
• Guide patients through post-discharge care options and resources.
• Maintain knowledge of regulations affecting patient care and discharge planning.
• Stay informed on payer requirements and reimbursement practices.
• Identify barriers to efficient care delivery and improve outcomes.
• Document assessments, interventions, and care plans in the EMR.

Skills

Assessment skills

Communication skills

Counseling skills

Advocacy skills

Conflict management

Education

MSW CSWE-accredited

Job description

Atrium Health Wake Forest Baptist in North Carolina is seeking a Social Worker II to provide social work services, complex discharge planning and care coordination for patients and families. You will identify community resources, refer patients, and communicate psychosocial issues to the care team to support safe transitions.

The role emphasizes collaboration with a multi-disciplinary team to improve patient outcomes, perform psychosocial assessments, develop and monitor care plans, and advocate