Social Services Coordinator - Telehealth

The Social Services Coordinator supports patients during the critical weeks after a hospital or facility discharge. Transitional Care Management services will be provided via telehealth by identifying and addressing the social and logistical barriers that affect their health. Working virtually with patients, families, providers, and community organizations, the coordinator connects patients to resources and ensures smooth transitions across care settings. This role helps make virtual care accessible, equitable, and effective.

• Connect patients with community resources
• Maintain an up-to-date directory of local and regional resources
• Follow up on referrals to confirm services were received and needs were met
• Track patient engagement and follow escalation protocols
• Assist with arranging post-acute services

• Maintain patient confidentiality in accordance with HIPAA and organizational policy
• Adhere to state telehealth regulations, mandatory reporting requirements, and professional ethics standards
• Contribute data for quality improvement, program reporting, and grant or contract requirements

• Educate patients and families on community services, and self-management resources
• Build and maintain relationships with community partners and referral agencies
• Participate in outreach or program development initiatives as assigned

• 2+ years of experience in social services, case management, or care coordination, preferably in a healthcare setting
• Knowledge of community resources, public benefit programs, and social determinants of health
• Excellent written and verbal communication skills
• Proficiency with EHR systems, video conferencing platforms, and standard office software
• Ability to work independently and manage a caseload in a remote environment

• Licensed Clinical Social Worker (LCSW), or state-equivalent licensure
• Experience delivering services via telehealth
• Bilingual or multilingual abilities
• Experience serving Medicaid, Medicare, or other underserved populations
• Familiarity with Transitional Care Management and CMS requirements
• Experience in transitions of care, hospital discharge planning, or readmission reduction

• Remote; requires a private, HIPAA-compliant workspace with reliable high-speed internet
• Extended time at a computer and on video or phone calls
• Flexible scheduling may be needed to accommodate patient availability
• Organization-provided laptop and secure software access

This job description describes the general nature and level of work performed in this position. It is not intended to be an exhaustive list of duties, responsibilities, qualifications, or requirements. Responsibilities may be modified based on organizational needs, patient population, regulatory requirements, and program.

Pay: $30.00 - $33.00 per hour

Expected hours: 40.0 per week

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

• California (Required)

Work Location:

Remote