Complex Inpatient Medical Social Worker
Core
Expert resource guiding patients, families, and clinical partners through complex psychosocial needs and care transitions in an inpatient setting.
Role type
Senior IC medical social worker (care coordination)
Builds
Safe, effective, and timely transitions across the care continuum for socially complex patients
Domain
Healthcare / Social Work
Deliverable
physical/clinical work
Required skills
psychosocial assessment, discharge planning, care management, community resource coordination, regulatory compliance, multidisciplinary team leadership, utilization review, advocacy
Preferred skills
mentorship of frontline staff, data analysis for patient outcomes, knowledge of post-acute placement venues
Technologies
SharePoint
Responsibilities
Conduct thorough psychosocial assessments and implement patient-family centered care plans; Lead multidisciplinary rounds to resolve barriers to discharge and expedite care delivery; Coordinate post-acute placements, palliative/hospice services, and community referrals; Manage patient length of stay and care continuum to reduce readmissions; Advocate for patient needs and ensure compliance with CMS and regulatory guidelines; Educate patients and families on advance directives, legal proceedings, and community resources.