Social Worker

Job Description

Job Description

Social Worker 

Facility: Nexus Children’s Hospital – Shenandoah

About Nexus Children’s Hospital – Shenandoah

Nexus Children’s Hospital – Shenandoah is a 50-bed specialty inpatient hospital providing advanced, structured care for children and adults with complex medical and behavioral health needs. Our campus includes a 16-bed ICU/Medical-Surgical Unit for high-acuity medical care and a 34-bed Medical-Behavioral Unit supporting patients with co-occurring medical and psychiatric conditions.

We specialize in treating brain and spinal cord injuries, chronic illnesses, neurobehavioral disorders, and adolescents with complex co-occurring diagnoses. At Nexus Health Systems, we are bridging medical and behavioral care so no patient falls through the cracks. Our programs deliver compassionate, specialty-driven treatment that helps individuals heal, grow, and achieve long-term success — because at Nexus, we’re mending minds.

Position Summary

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 Clinical & Assessment

• 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.

Family Support & Counseling

• 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.

Communication & Coordination

• 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.

Discharge Planning

• 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.