ASW | Accredited Social Worker - Transitions of Care

Job Summary : This role focuses on promoting optimal social and emotional functioning to help patients effectively utilize healthcare and related services, aiming to achieve their best possible health outcomes. The social worker understands the impact of psychosocial factors on recovery and provides patient-centered assessments to facilitate smooth transitions from hospital care.

Essential Responsibilities :

• Conduct discharge screenings, evaluations, and develop discharge plans, especially for patients with complex needs.
• Reassess and monitor discharge plans for changes in patient condition.
• Advocate for patients alongside their support network and healthcare team.
• Provide interventions and emotional support to families during healthcare decision-making.
• Offer crisis intervention, adjustment support for illness, and bereavement assistance.
• Coordinate resources such as skilled nursing facilities, home care, hospice, infusion services, long-term acute care, and durable medical equipment.
• Ensure system integration and continuity of care through interdisciplinary collaboration.
• Manage adoptions and follow-up calls per Transitions of Care policies, including telephonic patient assessments and interventions.
• Provide resources to patients before or after admission to support effective discharge planning.
• Conduct chemical dependency and mental health assessments with referrals to treatment as needed.
• Perform readmission assessments and trend analysis.
• Issue Medicare Notification Letters.
• Assist with financial concerns by connecting patients to eligible programs and assistance resources.
• Assess and refer cases involving abuse (adult, child, sexual, domestic violence).
• Evaluate Social Determinants of Health and assist patients in navigating government and social service programs.
• Provide information and facilitate execution of advance directives.
• Participate in departmental, hospital, and community meetings and initiatives relevant to the role.

Education and Experience Required :

Licensure / Certifications : Valid and active state social work licensure is required.

Work Shift : 4th Shift

This position serves a regional area within the United States Midwest region.