Certified or Licensed Social Worker

Schedule:

Part-time, 16-20 hours per week

Reports To:

Director of Nursing

The Certified or Licensed Social Services Director is responsible for planning, organizing, implementing, and evaluating social services for patients and families in a Critical Access Hospital setting. This part-time role supports patients across acute, outpatient, emergency, and swing-bed services by addressing psychosocial needs, discharge planning, care coordination, community resource referrals, and transition-of-care needs. The Social Services Director works collaboratively with nursing, providers, rehabilitation, case management, and community agencies to promote safe discharges, patient rights, continuity of care, and compliance with applicable hospital, state, and federal requirements.

• Bachelor's degree in Social Work, Human Services, Counseling, Psychology, Sociology, or a related field required, unless otherwise defined by state licensure or certification standards.
• For Nebraska positions, the incumbent must hold and maintain a current credential in good standing through the [Nebraska Department of Health and Human Services](), as applicable to the scope of the role and the title used, such as [Certified Social Worker (CSW)](), [Certified Master Social Worker (CMSW)](), [Licensed Mental Health Practitioner (LMHP)](), or [Licensed Independent Mental Health Practitioner (LIMHP)](). In Nebraska, a person must be appropriately credentialed to represent themselves as a social worker, and CSW/CMSW credentials do not authorize independent mental health practice.
  
  If the position includes clinical mental health services beyond social work activities, the individual must also hold the Nebraska mental health practice credential required for that scope.
• Minimum of two years of experience in healthcare, hospital, post-acute care, case management, discharge planning, or social services preferred; rural health or Critical Access Hospital experience strongly desired.
• Knowledge of psychosocial assessment, discharge planning, crisis intervention, community resources, patient rights, and interdisciplinary care coordination.
• Knowledge of Medicare, Medicaid, post-acute services, community-based resources, and regulatory documentation standards relevant to hospital and swing-bed services.
• Strong communication, organization, time management, problem-solving, and interpersonal skills.
• Ability to work independently in a part-time role while maintaining timely follow-up, documentation, and collaboration with the care team.
• Proficiency with electronic medical records, standard office software, and documentation systems.

• Provides social services support to patients and families, including psychosocial assessment, crisis intervention, counseling, support, and referral services.
• Coordinates and documents discharge planning activities in collaboration with the interdisciplinary team, patient, family, and caregivers, with a focus on patient goals, treatment preferences, safe transitions, and reduction of avoidable readmissions.
• Identifies patients at risk for complex discharge, social barriers, limited support systems, abuse or neglect concerns, behavioral health needs, financial hardship, housing instability, transportation barriers, or lack of access to community resources.
• Assists with care coordination for patients requiring post-acute services, including home health, hospice, durable medical equipment, long-term care placement, behavioral health services, community-based services, and other appropriate referrals.
• Supports swing-bed patients and care teams with social service needs, discharge preparation, resident rights support, family communication, and coordination of post-discharge services.
• Participates in interdisciplinary rounds, care conferences, utilization discussions, and transition planning meetings as requested.
• Educates patients and families on available community resources, advance care planning resources, financial assistance programs, insurance-related concerns, and post-discharge support options.
• Maintains current knowledge of local, state, and federal regulations affecting hospital social services, discharge planning, patient rights, mandatory reporting, confidentiality, and swing-bed related requirements.
• Completes timely, accurate, and thorough documentation in the medical record and any required departmental logs, reports, or quality tracking tools.
• Serves as a liaison with external…