Social Worker, Patient​/Health Advocate

Social Worker Summary

In collaboration with patients, families, case managers, physicians, and the interdisciplinary team, the Social Worker I provides psychosocial assessment, counseling, care coordination, and discharge planning. This role identifies barriers to care, connects patients with community resources, supports transition planning, and uses clinical interventions to address immediate patient and family needs.

• Screen patients for social work needs and complete full psychosocial assessments as needed.
• Provide direct psychosocial support, care coordination, and transition planning for assigned patients.
• Collaborate with the interdisciplinary team to support care progression and optimize patient outcomes.
• Develop and implement plans to address psychosocial barriers to discharge.
• Maintain timely, accurate documentation in accordance with departmental and regulatory standards.
• Connect patients and families with appropriate community, local, regional, and national resources.
• Assist with referrals for guardianship, adoption, psychiatric services, abuse/neglect/IPV concerns, end-of-life issues, and charity care.
• Facilitate family meetings and participate in interdisciplinary rounds as needed.
• Participate in quality improvement activities, committee work, and coverage for absences/vacancies.
• Provide on-call coverage and home visits as required.
• Complete supervision as required by COMAR regulations.
• Perform other duties as assigned.

• Provide psychotherapy and psychosocial care for assigned patients.
• Support patient/family engagement, education, crisis intervention, grief counseling, and mandated reporting as needed.
• Monitor medication effectiveness, observe for side effects, and notify the physician of concerns or needed changes.

Education:

• MSW required

Licensure:

• Maryland LMSW required

Knowledge, Skills, and Abilities:

• Strong interpersonal and collaboration skills
• Knowledge of community resources
• Ability to gather, synthesize, and communicate relevant patient information
• Excellent written and verbal communication skills
• Strong time management and prioritization skills
• Proficiency with electronic medical records, email, and standard office technology