Clinical Social Worker
Core
Acts as a patient advocate to coordinate, negotiate, and procure services and resources for transitional care planning to facilitate quality and cost-effective patient 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 / Population Health
Deliverable
client delivery
Required skills
Crisis intervention, psychosocial assessment, care coordination, resource navigation, interdisciplinary collaboration, regulatory compliance documentation
Preferred skills
Pediatric and geriatric care experience, community population experience, medical terminology knowledge, EPIC EMR proficiency
Technologies
EPIC, Outlook
Responsibilities
Respond to and prioritize urgent high-risk cases (crisis, depression screening, CPS/APS referrals); Complete and document initial psychosocial assessments within 24 hours; Attend interdisciplinary rounds to report psychosocial barriers and resource limitations; Coordinate with internal teams and external agencies to ensure timely discharge; Escalate high-risk cases requiring additional resources; Provide regulatory notifications (MOON, IMM, DND, HINN, ABN).
