Care Coordination Master Social Worker

Job Summary And Responsibilities

As our Social Worker, you will be a compassionate advocate, providing vital support and guidance to individuals and families facing complex challenges.

Every day, you will conduct psychosocial assessments, develop care plans, provide counseling and crisis intervention, and connect clients to resources. You'll advocate for clients and collaborate with multidisciplinary teams to ensure holistic support and promote well‑being.

To be successful in this role, you will possess exceptional interpersonal skills, empathy, strong knowledge of community resources, and proven crisis management abilities, fostering positive change and client empowerment.

• Providing developmentally appropriate care for all populations served: plan for the safe discharge and continuity of care, recognize and plan for the unique needs of all ages, the physically disabled, mentally ill, chronically ill, terminally ill, and vulnerable patients.
• Advocacy and education: patient/family self‑care management; patient/family health management education; bioethics referrals and management; physician, staff, and community education; case/care management/coordination education and training; risk management identification and referral.
• Psychosocial management: crisis intervention; psychosocial assessment/functioning; counseling support and referral; abuse/neglect/trafficking identification, assessment, and referral (partner, child, elder, etc.); family issues affecting care; coping/emotional adjustment; grief/bereavement support (individual and group); adoption, surrogacy, and safe surrender support, management, and resources; health/wellness promotion; substance abuse screening, management, and resources; psychiatric screening, management, and resources; staff support; assessing, addressing, managing, and resources related to social determinants of health (e.g. housing and food insecurity, transportation).
• Patient/Family Care Conferences: interdisciplinary care communication/coordination related to continuity/transitions of care planning and management.
• Continuity/Transition Management:
  As part of Care Management/Coordination team, facilitation of patient decisions and communications regarding post‑acute care; professional responsibility for knowledge of community resources related to clinical social work scope of service and functions and social worker discretion; maintaining appropriate up‑to‑date resource lists; education for patients/families about availability of community resources; mental health service and support coordination; grave disability, palliative care/end‑of‑life, and hospice patient/family support, referrals, and management;
  
  interventions, management, and coordination of transition planning for psychosocially complex cases.
• Community Resource Coordination: life‑care planning; expert consultation on health care resource management; team and patient education regarding various health‑related insurance/support programs (e.g. CCS/Medicare/Medicaid/SSI); building and maintaining community relationships to address needs of patients experiencing homelessness and to meet other social determinants of health needs.

• Masters in Social Work and 1‑Year Post‑MSW experience or Social Work internship in a clinical or medical setting, upon hire.
• Master Social Worker:
  Texas, upon hire.

• Minimum 3‑Year Post‑MSW healthcare experience.

The Woodlands Hospital is a primary and secondary care hospital serving North Harris and Montgomery counties. Clinical services include cardiovascular services, diagnostic imaging, women’s services (digital mammography and bone density studies), neurosciences, pediatric care (Newborn and Level II nurseries) and surgery, pathology and pulmonary services, and sleep disorders. Clinical affiliations include The University of Texas MD Anderson Cancer Center’s Radiation Treatment Center, and Texas Children’s Hospital.

$34.00 - $50.58 /hr