Licensed Social Worker - Post-Acute and Transitional Care

Community Health Centers of America is a premier multi-specialty group focused on improving the health of the community through excellence in clinical care and at partner care facilities. We are looking for an Licensed Social Worker to work full-time with us in our Fair Oaks office supporting the health program for partner care facilities throughout the Sacramento area.

The Licensed Social Worker supports CHCA's mission to serve the underserved by ensuring patients in post-acute and transitional care settings experience safe, timely, and supportive transitions to lower levels of care or community living. This role provides psychosocial support, resource connection, and care coordination for patients as they move between hospitals, skilled nursing facilities, residential care facilities, and home or outpatient care.

The Social Worker collaborates closely with CHCA's primary care, psychiatry, and care management teams to address barriers to care, support patient independence, and reduce avoidable readmissions.

Essential Functions and Responsibilities :

Patient Support and Transition Planning

• Conduct comprehensive psychosocial assessments for post-acute patients referred by CHCA providers or facilities.
• Develop individualized transition and care plans addressing social determinants of health, resource needs, and family / caregiver involvement.
• Coordinate services for housing stability, home health, hospice, DME, transportation, and medication management as needed.
• Serve as the primary liaison between SNF / RCFE staff, hospital discharge planners, CHCA clinic providers, and community agencies.
• Facilitate communication between patients, families, and healthcare teams to ensure continuity of care and understanding of post-discharge plans.

Care Coordination

Community Resource and Advocacy

Quality and Compliance

Work Environment

Benefits

Requirements

POSITION REQUIREMENTS

Salary Description

50.00 - 70.00 / hour, depending on experience