Clinical Care Social Worker
Core
Plans and coordinates care for patients with complex psychosocial needs, managing discharge planning, crisis intervention, and resource referrals across the continuum of care.
Role type
Clinical Care Social Worker
Builds
Transition and discharge plans for patients requiring post-acute care, homecare, or specialized medical equipment.
Domain
Healthcare / Social Work
Deliverable
client delivery
Required skills
Psychosocial assessment, crisis intervention, discharge planning, resource management, eligibility determination for social programs, knowledge of federal/state assistance programs, care coordination, documentation, advocacy for abuse/neglect/domestic violence cases, payer regulation knowledge.
Preferred skills
1-3 years of clinical social work experience.
Technologies
Electronic health records, quality screens for readmission avoidance.
Responsibilities
Manage transition/discharge planning for assigned patients; collaborate with multidisciplinary teams to facilitate patient transitions; monitor patient progress and intervene as necessary; maintain knowledge of community resources and assistance programs; provide social work assessments for complex crises including mental health and substance abuse; initiate referrals to post-acute services; communicate discharge plans to teams and families; document interactions and planning activities; assist patients with medical power of attorney and advanced directives; utilize clinical expertise for abuse, neglect, and domestic violence reporting; coordinate financial management and entitlement programs; communicate with payors to resolve reimbursement issues; provide education to staff and patients on transition planning.
Seniority
Mid-level, hands-on IC