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Role & Practice Overview:

Setting: Hospital / Inpatient Acute Care.
Primary Focus: High-level triage and assessment of complex psychosocial issues, discharge planning barriers, risk of readmission, placement needs, and community service coordination within 24 hours of patient admission.

Schedule & Hours:

Shift Type: Day Shift (Monday – Friday).
Hours: 8 hours per day / 40 hours per week (40-Hour Weekly Guarantee).
Weekend Requirements: None.
On-Call Requirements: None.

Duties & Core Responsibilities:

Triage & Referrals: Perform complex psychosocial assessments within 24 hours of admission; receive and process social work referrals from RN Care Managers based on established triggers.
Discharge Planning & Barrier Mitigation: Identify length-of-stay (LOS) barriers early; formulate individualized, safe discharge plans in consultation with patients, families, physicians, and multidisciplinary teams.
Community Resource Coordination: Assess needs and connect patients/families to post-acute services, community resources (e.g., Meals on Wheels, sitters), and follow-up care.
Readmission & Complex Care Management: Evaluate readmission risks, manage complex situations, advocate for patient autonomy, and execute targeted continuum-of-care interventions.
Interdisciplinary Collaboration: Participate in unit rounds, huddles, and family care conferences; work closely with RN Care Managers and post-acute agencies to ensure safe care transitions.
EMR Documentation & Operations: Document assessments, interventions, and barriers in the EMR; monitor insurance coverage guidelines; track and report avoidable stay days or service delays to leadership.

Submission & Candidate Requirements:

Licensure: Active Michigan Social Work License (LMSW or LBSW) [REQUIRED AT SUBMISSION].
- LMSW / LBSW certification required within 1 year of eligibility.
Clinical Experience: Prior Acute Care hospital experience [REQUIRED].
Preferred Experience: 3+ years of acute hospital care or healthcare social work experience [PREFERRED].
Certifications: Active AHA BLS (or ARC / MTN equivalent) [PREFERRED].

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