Social Worker, Patient​/Health Advocate

Centers Health Care is seeking a compassionate Social Worker to join our Healthcare & Medical Services team. In this role, you will assess patient needs, coordinate care plans, provide counseling, and connect individuals and families with appropriate community resources. You will collaborate with an interdisciplinary care team to support patient well-being and advocate for patient rights. We foster an inclusive, collaborative culture that values continuous learning and innovation, offering strong opportunities for professional growth and development in a supportive, mission-driven environment.

Responsibilities

• Conduct comprehensive psychosocial assessments of patients and families to identify strengths, needs, and goals
• Provide individual and family counseling, emotional support, and crisis intervention in a healthcare setting
• Develop, implement, and regularly update psychosocial care and discharge plans in collaboration with the interdisciplinary team
• Coordinate safe and appropriate transitions of care, including discharge to home, rehabilitation, skilled nursing, or community-based programs
• Educate patients and caregivers about available benefits, resources, and support services, including Medicaid, Medicare, insurance, and local agencies
• Advocate on behalf of patients and families to secure necessary services, equipment, and follow-up care
• Maintain accurate, timely, and compliant documentation in electronic health record systems
• Participate in interdisciplinary rounds, case conferences, and care planning meetings to represent the psychosocial perspective
• Collaborate with community organizations, social service agencies, and support networks to facilitate referrals and resource connections
• Support quality improvement initiatives and contribute feedback on workflows, services, and patient experience
• Adhere to professional ethical standards, patient confidentiality regulations, and organizational policies
• Engage in ongoing professional development, training, and supervision to maintain and enhance clinical skills

Required Skills

• Clinical assessment and psychosocial evaluation
• Patient and family counseling
• Crisis intervention and de-escalation
• Discharge planning and care coordination
• Knowledge of community resources and social services
• Familiarity with Medicaid, Medicare, and insurance processes
• Electronic health record (EHR) documentation
• Interdisciplinary team collaboration
• Case management and caseload prioritization
• Cultural competency and trauma-informed care
• Advocacy and patient rights
• Verbal and written communication
• Time management and organization