Social Worker (Social Work)

(List Format):

• Perform high-level triage of all patients within 24 hours of admission, focusing on complex psychosocial, financial, placement, and community service needs.
• Receive and act upon RN Care Manager referrals based on established Social Work Triggers.
• Identify barriers to patient care early, develop plans with patients, families, care teams, payers, and community resources.
• Assess and address patient and family needs for support and community services; provide education and referrals.
• Evaluate risk of readmission for targeted patient populations and initiate interventions to support care transitions.
• Arrange and participate in family care conferences and interdisciplinary meetings; provide consultation and support.
• Identify and report care delays or variances to leadership as per the established plan of care.
• Recognize and communicate patient/family preferences, needs, and strengths to the interdisciplinary team.
• Conduct interviews to assess psychosocial situations and establish key family contacts.
• Develop discharge plans in collaboration with patients, families, physicians, and care teams.
• Manage and advocate for complex cases, including those requiring specialized discharge planning.
• Utilize knowledge of insurance and coverage guidelines to optimize resource use.
• Document assessments, plans, interventions, and barriers in the EMR; ensure information is transferred to post-acute agencies.
• Collaborate with RN Care Managers and the healthcare team to ensure safe, timely patient transitions.
• Partner with external agencies to promote care continuity and patient/family empowerment.
• Represent the care management department on committees and performance improvement projects.
• Perform other related duties as assigned.

Requirements

• Licensed Master’s Social Worker (LMSW) or eligible; must obtain certification within one year and maintain continuing education [REQUIRED]
• State licensure as a Licensed Bachelor Social Worker (LBSW) or eligible; must obtain certification within one year and maintain continuing education [REQUIRED]
• Acute care experience [REQUIRED]
• Three years’ experience in acute hospital care or social work [PREFERRED]
• Basic Life Support (BLS) certification [PREFERRED]
• Michigan state license [REQUIRED]