Clinical Social Worker
Core
Acts as a patient advocate to coordinate, negotiate, and procure services and resources for transitional care planning of patients to facilitate quality and cost-effective outcomes.
Role type
Clinical Social Worker (Patient Advocate)
Builds
Transitional care plans and discharge pathways for patients across ED, inpatient, and post-acute settings.
Domain
Healthcare / Social Work
Required skills
Psychosocial assessment, care coordination, crisis intervention, resource management, interdisciplinary collaboration, regulatory compliance documentation, SMART goal formation
Preferred skills
Pediatric and geriatric care experience, knowledge of medical terminology, EPIC EMR proficiency
Technologies
EPIC, Outlook
Responsibilities
Respond to and prioritize urgent high-risk cases (crisis, CPS/APS referrals); coordinate community and resource-specific referrals; complete initial psychosocial assessments within 24 hours; participate in interdisciplinary rounds to identify psychosocial barriers; communicate with care teams to remove discharge barriers; escalate high-risk cases; provide regulatory notifications (MOON, ABN, etc.).
Seniority
Mid-level, hands-on IC