Job Description

Transitional Care Social Worker

Essential Job Duties:

• Conduct social work assessments to evaluate the psychosocial needs, preferences, and goals of the patients. Actively participate in team meetings to develop care plans for participants.
• Implement and document social work interventions as outlined in each participant’s care plan. These interventions may include organizing necessary resources and services, assisting with care transitions, and providing individual or group counseling and case management.
• Collaborate with the primary care physician and other care team members to ensure seamless transitions of care across various settings, such as hospitals, skilled nursing facilities, and participants' homes.
• Initiate, coordinate, and facilitate care conference meetings to enhance care coordination among the care team, participants, and their support networks, including family and informal caregivers.
• Assist with discharge planning for participants who choose to disenroll from the program.

Requirements

Job Requirements:

• Master’s Degree in Social Work (MSW) required
• Minimum of one (1) year of experience with a frail or elderly population
• Previous experience coordinating and facilitating care conference meetings

Benefits

Benefits:

• Medical insurance coverage (Medical, Dental, Vision)
• 17 days of personal time off (PTO), 12 holidays, and sick time
• 401k
• Growth opportunities
• And additional benefits

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