Social Worker

Social Worker

The Social Worker Case Manager is a vital member of the interdisciplinary team, supporting patients and families from admission through discharge. This role focuses on safe, effective discharge planning, psychosocial assessment, patient/family advocacy, and strengthening communication between families and clinical teams. The Social Worker helps families navigate stressors, understand the care process, and access needed community resources — ensuring each patient transitions safely and smoothly back into their community.

Key Responsibilities

• Complete social service screening, psychosocial assessment, and discharge planning assessment for each admission/readmission within 72 hours.
• Ensure assessments include all required policy elements and are documented clearly in the medical record.
• Develop a social services plan of care and integrate it into the interdisciplinary care plan.
• Update care plans weekly during team conference.
• Identify patients and families in need of counseling and provide support with warmth, empathy, and professionalism.
• Help patients and families focus on and resolve psychosocial issues affecting their hospital experience.
• Act as a patient/family advocate during care plan discussions and conferences.
• Facilitate effective communication between families and the interdisciplinary treatment team.
• Coordinate family conferences with case managers and physicians during admission and discharge planning.
• Work collaboratively with clinical staff to support required family education before discharge.
• Communicate team recommendations and level-of-care needs to families after each treatment conference.
• Identify and document discharge barriers and collaborate with the team to resolve them early.
• Maintain care provider relationships and locate appropriate community resources for post-discharge needs.
• Provide verbal and written referrals to patients and families.
• Initiate early communication with CPS when discharge barriers present significant safety or care concerns.
• Document progress, barriers, and interventions in the medical record thoroughly and timely.
• Maintain communication with staff members regarding updates in patient care.
• Perform other duties as assigned to support patient care and hospital operations.

Qualifications

• Bachelor's degree in Social Work required
• Master's degree in Social Work preferred
• Minimum of 2 years of experience as a Social Worker or Case Manager
• Experience in a medical setting preferred
• Active Texas Social Work license required