Care Coordinator SW

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice?

At Wellstar, our mission is simple, yet powerful: to enhance the health and well‑being of every person we serve.

Day (United States of America)

The Care Coordination Social Worker (CC SW) is responsible for assessing transitional care needs, coordinating care across the continuum, and engaging with patients and families to ensure care needs are met. The CC SW serves as a key resource for patients and a consultant to the care team regarding psychosocial and resource needs. In conjunction with the patient and physician, the CC SW will assess, coordinate, and implement a safe, timely discharge plan to the next appropriate level of care, integrating patients' transition plans into individualized discharge plans based on needs and available resources.

• Implements discharge planning and provides marchés resource information in a timely and efficient manner for patients.
• Identifies and documents barriers for timely disposition.
• Understands eligibility processes and criteria for both private and public local, state, and federal resources to assist in planning a safe and appropriate transition for discharge.
• Responds to referrals for patient assistance from RN Care Coordinators, physicians, and the care team.
• Participates in Interdisciplinary Rounds with the patient’s care team to confirm estimated date of discharge and make recommendations for the best level of care transition at discharge.
• Initiates or facilitates post‑acute referrals through departmental processes for timely Definitions transition to the next level of care.
• Provides financial needs assessment for patients requiring assistance for follow‑up care throughout the continuum.
• Advocates and partners with the patient and family to empower them to make autonomous health‑care decisions, keeping the patient’s wishes at the center of discharge planning.
• Acknowledges and respects cultural or religious beliefs in providing service continuity.
• Participates in the development of protocols, procedures, and performance improvement activities to optimize patient outcomes.

• Based on preliminary screening, initiates assessment of patients’ psychosocial risk factors and resource availability for discharge.
• Partners with the PAS, financial counselors, and/or UM nurse to assess insurance and coverage requirements for all payers.
• Collaborates with patients, families, physicians, and other care team members to fully establish and support care progression and discharge plans.

• Completes the initial psychosocial/functional assessment and documents it in the medical record.
• Ensures all records are up‑to‑date and documentation is clear and concise.
• Ensures timely and accurate documentation of progress notes and interactions with patients/families.
• Registers all services arranged or delivered in the Electronic Health Record.
• Tracks avoidable days and reports trends that lead to undesirable outcomes.

• Completes all initial and ongoing professional competency assessments, mandatory education, and population‑specific education.
• Supports departmental goals that contribute to organizational success.
• Serves as a preceptor or mentor for social work students (when appropriate).
• Performs other duties as assigned.
• Complies with all Wellstar Health System policies, standards of work, and code of conduct.

• Bachelor’s in Social Work or Master’s in Social Work (Preferred)

• BLS – Basic Life Support, ARC‑BLS – American Red Cross Basic Life Support, or BLS‑I – Basic Life Support – Instructor

Minimum one year of experience in healthcare in an acute care setting, related field, skilled care environment, community ചെയ്യുന്ന, or educational internship in care coordination. Background in medical social work in an acute care setting is preferred.

• Excellent written and verbal…