Social Worker 2, Transition of Care

Apply now Job No: 497227 Department: Social Work Operating Local Title: Social Worker 2, Transition of Care Budget Title: Teaching Hospital Social Worker II Work Type: Full Time Location: Brooklyn, NY Categories: Clinical, Patient Care Are you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors. Job Summary The Department of Social Work at SUNY Downstate Health Sciences University is seeking a full-time Transition of Care Social Worker 2. The successful candidate will: Provide both inpatient and outpatient coverage, transition of care and post-acute follow up and will address patients post-discharge related issues. Cover for Transplant service to ensure adequate coverage at all times. Provide coverage in the outpatient transplant clinic can inpatient transplant unit. Be an integral part of the hospital multidisciplinary team, and work with patients and their families and caregivers, to assess patient and family psychosocial and discharge planning needs relevant to medical treatment. Provide crisis intervention, emotional support, resource information, discharge planning and legal reporting. Assess, plan and support patients to cope with social, emotional, economic and environmental problems. Help patients maintain their independence in the community. Work jointly with healthcare providers on social issues that may affect patients health and well-being. Screen and assess the psychosocial needs of the patient and family to develop, communicate, and implement an effective and comprehensive plan for psychosocial interventions. Provide social work services to specialty areas within the hospital that require and MS for regulatory requirements. Participate in daily multidisciplinary huddles in the unit assigned to discuss plan of care and discharge planning needs. Proactively collaborate with the interdisciplinary team to develop and carry out appropriate discharge plans. Coordinate transition of are needs as homecare services, DME, and placements for nursing home, acute and sub-acute rehab facilities in a timely manner. In coordination with Care Management Assistants, process placement of patients in SNF, sub-acute and nursing homes through discharge and closing the case within 24-hours post-discharge. Provide grief and bereavement counseling to patients, families and caregivers. Initiate and oversee guardianship referrals in collaboration with the Risk Management Department. Perform legal reports for suspected child abuse and elder abuse, and domestic violence referrals. Serve as the liaison to Administration of Children Services and Adult protective Services. Provide patient/family conferences and education as needed, to ensure appropriate length of stay and transition care from the hospital. Perform other multiple tasks, responsibilities and obligations as it pertains to the position, as the job duties are not limited to the aforementioned description. Required Qualifications Master's Degree in Social Science. New York State Social Work Licensure (LCSW and/or LMSW). 1+ year of social work experience. Knowledge of Federal, State, and TJC regulations. Knowledge of Medicare, Medicaid and Managed Care Standards, requirements, benefits and benefits administration. Knowledge of state and federal programs that provide financial assistance to underserved populations. Knowledge of community resources. Proficiency in use of PC, Microsoft Office Suite, and clinical applications. Ability to work with diverse patient populations, with knowledge and sensitivity to cultural and spiritual influences impacting on patient care. Social work assessment and counseling skills, to include grief and bereavement counseling, alcohol, and drug intervention, and support for victims of abuse, neglect and violence. Possess a positive attitude, motivation and good interpersonal skills. Excellent verbal and written communication skills. Ability to work in a multidisciplinary team approach. Ability to work independently with minimal supervision. Or, a satisfactory equivalent combination of experience, education and training. Preferred Qualifications Hospital and care management experience and CCM preferred. Work Schedule Monday to Friday; 9:00am to 5:00pm (Full-Time) Salary Grade/Rank Salary Range: Commensurate with experience and qualifications. Executive Order Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor’s Office of Employee Relations at View phone number on click.appcast.io or via email View email address on click.appcast.io . Equal Employment Opportunity Statement SUNY Downstate Health Sciences University is an affirmative action, equal opportunity employer and does not discriminate on the basis of race, color, national origin, religion, creed, age, disability, sex, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, criminal conviction, and all other protected classes under federal or state laws. Women, minorities, veterans, individualswith disabilities and members of underrepresented groups are encouraged to apply. If you are an individual with a disability and need a reasonable accommodation for any part of the application process, or in order to perform the essential functions of a position, please contactHuman Resources at View phone number on click.appcast.io. Advertised: April 01, 2026 Eastern Daylight Time Applications close: Open until filled #J-18808-Ljbffr SUNY Downstate Health Sciences University