Care Coordinator Social Worker

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 patients and families 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 the patient’s transitional care plan into individualized discharge plans based on needs and available resources. Specific Functions Within This Role Include Providing psychosocial assessments for patients to include timely and appropriate planning to advance the discharge plan. Relaying information about community‑based service offerings (e.g., indigent care referrals and assistance, specialty care or post‑acute placements, elder assistance) and offering guidance to patients and families to assist with multi‑system factors that affect psychosocial dynamics. Serving as a specialist on issues related to psychosocial and discharge needs, end‑of‑life care planning, and resource needs, providing information to aid decision making up to and including support for end‑of‑life. Partnering and offering feedback to the RN Case Manager concerning complex social determinants of health issues, situational dynamics, and social needs. Assisting with other assigned duties as needed. Core Responsibilities And Essential Functions Disposition Planning Implements discharge planning and provides resource information in a timely and efficient manner. Identifies and documents barriers for timely disposition. Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition. Responds to referrals for patient assistance from RN Care Coordinators, physicians, and the care team. Participates in Interdisciplinary Rounds with the patient care team to confirm estimated date of discharge and make recommendations for the best level of care transition. Initiates/facilitates post‑acute referrals through departmental processes for timely transition to the next level of care. Provides financial needs assessment for patients requiring assistance for follow‑up care throughout the continuum. Advocates and partners with the patient and family to empower autonomous healthcare decisions centered on patient wishes. Considers cultural or religious beliefs in providing service and continuity of care. Participates in the development of protocols, procedures, and performance improvement to optimize patient outcomes. Assessment Initiates assessment of psychosocial risk factors and available resources upon screening. Partners with the PAS, financial counselors, or UM nurse to assess insurance and coverage requirements for all payers to ensure adherence. Collaborates with the patient, family, physician(s), and care team to fully establish and support care progression and discharge plans. Documentation Initial psychosocial/functional assessment completed and documented in the medical record. Ensures all records are up‑to‑date and documentation is clear and concise. Ensures timely and accurate documentation of progress notes and interactions with patient and family. Accounts for and indicates all services arranged/delivered in the Electronic Health Record. Tracks avoidable days and reports trends that lead to undesired outcomes. Professional Development and Initiative Completes all initial and ongoing professional competency assessment, mandatory education, and population‑specific education. Supports departmental‑based goals that contribute to the organization’s success. Serves as a preceptor and/or mentor for social work students when appropriate. Performs other duties as assigned. Complies with all Wellstar Health System policies, standards of work, and code of conduct. Required Minimum Education Bachelor’s Social Work Master’s Social Work – Preferred Required Minimum License(s) And Certification(s) All certifications are required upon hire unless otherwise stated. Basic Life Support or BLS – Instructor Required Minimum Experience Minimum one year of experience in healthcare in an acute care setting, related field, skilled care environment, 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. Must possess 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 required. Knowledge of community and statewide resources and programs. Ability to work collaboratively with physicians, care team members, and patients/families throughout 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 Wellstar Health System