Care Coordinator SW PRN

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well‑being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives. Work Shift Day (United States of America) Job Summary The Care Coordination Social Worker (CC SW) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patient and family to assure care needs are met. Serves as a key resource for patients and a consultant to the care team regarding psychosocial and resource needs. In conjunction with the patient and physician, the CC SW will assess, coordinate, and implement a timely, safe patient discharge plan to the next appropriate level of care. The role integrates and coordinates transition plans based on individual needs and available resources. Specific functions include providing psychosocial assessments, relaying community‑based service information, guiding patients and families on psychosocial dynamics, advancing end‑of‑life care planning, supporting the RN Case Manager on social determinants of health, and may include additional duties. Core Responsibilities and Essential Functions Disposition Planning Implements discharge planning and provides timely resource information. Identifies and documents barriers to timely disposition. Understand eligibility processes for private and public resources. Responds to referrals from RN Care Coordinators, physicians, and the care team. Participates in Interdisciplinary Rounds to estimate discharge date and recommend level of care. Initiates and facilitates post‑acute referrals for timely transition. Provides financial needs assessment for follow‑up care. Advocates and partners with patients and families to empower autonomous decisions. Allows for cultural or religious beliefs in providing continuity of care. Participates in developing protocols, procedures, and performance improvement initiatives. Assessment Initiates assessment of psychosocial risk factors and resource availability. Partners with PAS, financial counselors, and UM nurse to assess insurance coverage. Collaborates with patient, family, physician, and care team to support discharge plans. Documentation Completes initial psychosocial/functional assessment and documents in medical record. Ensures all records are up to date and documentation is clear and concise. Provides timely and accurate progress notes and interactions with patient/family. Accounts for all services arranged or delivered in the Electronic Health Record. Tracks avoidable days and reports trends leading to undesired outcomes. Professional Development and Initiative Completes all initial and ongoing professional competency assessments and mandatory education. Supports departmental goals contributing to organizational success. Serves as a preceptor or mentor for social work students when appropriate. Performs other duties as assigned and complies with all Wellstar policies and code of conduct. Required Minimum Education Bachelor’s Social Work or Master’s Social Work (preferred) Required Minimum License(s) and Certification(s) BLS – Basic Life Support, ARC‑BLS – American Red Cross BLS, or BLS‑I – BLS Instructor LCSW – Licensed Clinical Social Worker GA, or LCSW‑P – Lic. Clinical Social Worker Provisional (1 Year) within 1 Year LMSW – Licensed Master Social Worker GA, or LMSW‑P – Lic. Master Social Worker Provisional (1 Year) within 1 Year Additional License(s) and Certification(s) Required Minimum Experience Minimum 1 year of experience in healthcare in an acute‑care setting, related field, or skilled care environment, or community or educational internship in care coordination. A background in medical social work in an acute‑care setting is preferred. Required Minimum Skills Excellent written and verbal communication skills; maturity, self‑confidence, objectivity, and a positive attitude. Self‑directed with the ability to function well under stress, handle change, and work in a fast‑paced environment. Strong assessment, interview, organizational, and problem‑solving skills. Knowledge of local, state, and federal regulations. Knowledge of community and state‑wide resources and programs. Ability to collaborate with physicians, care team members, patients, and families through the continuum of care. Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more. #J-18808-Ljbffr