Job Title: Hospital Social Worker (LSW) – Discharge Planning
Job Summary
We are seeking an experienced, compassionate Licensed Social Worker (LSW) to provide comprehensive social work services to patients and their families. In this role, you will assist patients in adjusting to acute illness, injury, or hospitalization while helping the clinical team understand the social, economic, emotional, and family factors impacting treatment and recovery.
You will play a vital role in discharge planning, evaluating risk factors, facilitating transitions to post-acute care levels, and mobilizing community resources to ensure safe, seamless patient dispositions across all populations.
Key Responsibilities
Discharge Planning & Care Coordination
- Care Transitions: Facilitate timely, safe, and appropriate discharges by coordinating transitions to skilled nursing facilities, board & care homes, assisted living, group homes, and hospice care.
- Complex Case Management: Identify social determinants of health and overcome complex discharge barriers for high-need patient populations.
- Plan Transmission: Ensure comprehensive discharge plans, orders, and clinical summaries are transmitted accurately to receiving post-acute care providers.
Clinical Assessment & Crisis Intervention
- Risk Evaluations: Assess patient and family coping mechanisms, prior level of function, support systems, and reactions to acute illness or disability.
- Protective Services: Provide crisis intervention and resource coordination for complex social situations, including child/elderly abuse or neglect, domestic violence, guardianship, foster care, and mental health placements.
- End-of-Life Support: Act as a supportive resource regarding palliative care decisions, end-of-life planning, and advance directives.
Candidate Requirements & Qualifications
Experience & Clinical Background
- Hospital Experience: Minimum of 2+ years of dedicated hospital social work experience in an acute care setting [Required].
- Discharge Planning: Demonstrated, hands-on experience managing acute hospital discharge planning and post-acute placement workflows [Required].
- Patient Scope: Proven experience working across all patient populations (pediatric, adult, and geriatric) [Required].
- EMR Proficiency: Hands-on experience utilizing Epic EMR for clinical documentation and care coordination [Required].
Licensure & Credentials
- Social Work Licensure: Active, unrestricted state license as a Licensed Social Worker (LSW) [Required].
Core Attributes
- Excellent crisis intervention, empathetic counseling, and active listening skills.
- Strong knowledge of community resources, healthcare reimbursement, and post-acute care placement criteria.
- Ability to collaborate seamlessly within a multi-disciplinary healthcare team in a fast-paced environment.