Discharge & Care Coordination Social Worker

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One! We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South. In collaboration with patient/family, physicians and the interdisciplinary team, the Social Worker I is responsible for coordination of patient-centered care and service delivery to facilitate optimal transitions and progression in care. The social worker is responsible for coordination and collaboration of care with patient, caregiver, physician and other members of the health care management team. The social worker collaborates and communicates with the healthcare team and involves the patient/family in the plan of care and responsible for coordinating and monitoring social work activities for the department and works closely with management to identify and resolve care issues. Models appropriate behavior as exemplified in MLH Mission, Vision and Values. Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence. A Brief Overview The Social Worker (MSW) is responsible for supporting safe, timely, and effective patient transitions throughout the acute care episode. This role focuses on psychosocial assessment, discharge planning, resource coordination, and patient/family support. The Social Worker collaborates with the interdisciplinary team to reduce barriers to care, prevent avoidable readmissions, and promote optimal patient outcomes. This position does not perform clinical therapy, diagnosis, or licensed clinical interventions. Models appropriate behavior as exemplified in MLH Mission, Vision and Values. What you will do Discharge Planning & Care Coordination Conducts psychosocial assessments to identify barriers to discharge, including social, financial, environmental, and support needs. Develops individualized discharge plans in collaboration with RN Case Managers, physicians, nursing, therapy, and other team members. Coordinates post-acute services such as home health, DME, transportation, community resources, and follow-up appointments. Ensures timely communication with families, caregivers, and external providers. Facilitates safe transitions to SNF, IRF, LTACH, or home settings. Patient & Family Support Provides education on available resources, benefits, and community programs. Assists patients and families with advance care planning discussions (non-clinical guidance only). Supports patients experiencing psychosocial stressors related to hospitalization, illness, or caregiving needs. Advocates for patient rights, preferences, and culturally appropriate care. Resource Navigation & Community Coordination Identifies financial, housing, transportation, and social support needs. Connects patients to community agencies, social service programs, and charitable resources. Coordinates with insurance case managers as needed for authorizations and benefits clarification. Assists with applications for Medicaid, disability, or other assistance programs (as allowed by hospital policy). Interdisciplinary Collaboration Participates in daily rounds, huddles, and care coordination meetings. Communicates patient needs, barriers, and discharge readiness to the care team. Works closely with RN Case Managers on complex cases requiring both clinical and psychosocial oversight. Documentation & Compliance Completes timely and accurate documentation in the electronic medical record. Adheres to CMS, Joint Commission, and hospital policies related to discharge planning and patient rights. Supports hospital initiatives such as readmission reduction, length-of-stay management, and value-based care models (e.g., TEAM Model) Additional Duties as required This position does not: Provide psychotherapy or clinical counseling Diagnose mental health conditions Conduct clinical risk assessments requiring licensure Perform clinical interventions reserved for licensed providers Education/Formal Training Requirements Required - Master's Degree Social Work Work Experience Requirements Experience in acute care, healthcare, social services or community resource coordination preferred. Knowledge of discharge planning, community resources, and healthcare systems strongly preferred. Licenses and Certifications Requirements Required - Licensed Master Social Worker Tennessee - Tennessee Board of Social Workers (or licensed within 12 months) Preferred - Licensed Master Social Worker Mississippi - Mississippi Board of Examiners for Social Workers Knowledge, Skills and Abilities Excellent interpersonal skills, with the ability to work collaboratively and cooperatively within an integrated interdisciplinary team. Comprehensive knowledge of community resources and the ability to effectively link patients and families to appropriate services. Ability to gather, synthesize, and summarize relevant data to support sound judgment and patient-centered clinical decision-making. Strong oral and written communication skills, enabling effective, professional interaction with hospital staff, agency partners, health care professionals, patients, and families. Ability to build constructive, therapeutic relationships with patients and families and to professionally manage difficult, sensitive, or complex social situations. Organizational skills to manage multiple tasks, caseloads, and projects while maintaining accuracy and workflow control. Ability to use initiative and exercise independent judgment, with well developed critical thinking and problem-solving skills. Demonstrated ability to develop and maintain effective working relationships with physicians and collaborate with health care professionals at all levels to achieve shared goals. Strong facilitation skills for patient/family meetings, team discussions, and care planning conferences. Proficiency with basic computer applications, including Word, internet navigation, and electronic medical record systems. Supervision Provided by this Position There are no supervisory responsibilities assigned to this job; may delegate to administrative support staff, if applicable Physical Demands The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion. Must have good balance and coordination. The physical requirements of this position are: medium work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently. The Associate is required to have close visual acuity including color, depth perception, and field of vision to perform an activity, such as assessing patients, preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading. Exposure to patient body fluids as well as exposure to hazardous or poisonous materials. Ability to react quickly to emergency situations; may be required to take call for nights/weekends on a rotating schedule. Our Associates are passionate about what they do, the service they provide and the patients they serve. We value family, team and a Power of One culture that requires commitment to the highest standards of care and unity. Boasting one of the South's largest medical centers, Memphis blends a friendly community, a thriving and growing downtown, and a low cost of living. We see each day as a new opportunity to make a difference in the lives of the people in our community. #J-18808-Ljbffr Methodist Le Bonheur Healthcare