• Care Coordination Social Worker

    Job ID
    Employment Type
    Full Time
    Hours Per Week
    350 7th Street North
  • Overview

    The Care Coordination Social Worker is responsible for effective and efficient utilization of hospital resources and assisting patients in receiving appropriate, high quality post-hospital care and service in a timely manner while working to remove barriers that create delays. Under general supervision, the Care Coordination Social Worker assesses patient and family psycho-social and discharge planning concerns relevant to medical treatment. Provides crisis intervention, emotional support, resources information, discharge planning and legal reporting. Arranges case conferences and facilitates bio-ethical consultations as necessary or as requested by patients, family, physicians or other members of the clinical team.


    • Care Coordination Social Worker works closely with physicians, bedside nurses, RN Care Coordinators, and associated clinical professionals to assist hospital patients in transitioning to a lower level of care.
    • Work in conjunction with the RN Care Coordinator to evaluate the results of the patient’s discharge screening in order to identify patients who will have discharge planning needs. Work as a team with the RN Care Coordinator to determine those patients who will be followed by the RN Care Coordinator, the Care Coordination Social Worker or both during the patient’s hospitalization. This discharge needs assessment will be conducted on all patients within 24 hours of admission and modified as the patient’s clinical condition and/or social needs change throughout their hospitalization.
    • Confers daily with the attending physician and consulting physician(s) to review and clarify progress toward discharge and identification of barriers for assigned patients.
    • Demonstrates high organizational skills, is empathetic and capable of multitasking in a high-stress clinical environment. Because families are often strained during hospitalizations, the Care Coordination Social Worker will demonstrate the ability to handle difficult situations in a way that promotes the best outcomes for the patient while reducing the hospital’s overall risk.
    • Assesses patients' and families' psychosocial needs; coordinates and facilitates post-acute care. Collaborates with and contributes to the interdisciplinary team's plans of care. Identifies and utilizes appropriate resources to optimize effective, efficient discharge plan. Provides support to patients and families and links them to appropriate community resources.
    • Refers patients/families and caregivers to appropriate resources regarding abuse/neglect/domestic violence, alcohol and substance abuse. Performs appropriate clinical interventions related to grief counseling, bereavement, adjustment, crisis intervention in order to support the process of transition planning.
    • Follows patients under the Baker Act and Marchman Act regulations to ensure regulatory requirements for patients’ rights and transition to the appropriate level of care are met.
    • Attend and actively participate in all departmental and interdepartmental meetings relative to Care Coordination and the proper utilization of hospital resources.
    • Must have a high level of interpersonal and communication skills and be a demonstrated team player. Must demonstrate reliability and accountability to patients, families and other team members.
    • Consistently documents appropriate information in the EMR to reflect the care coordination efforts during the patient’s hospitalization.
    • Collaborates with the patient and Utilization Review Team to identify post-acute care options that meet patient needs and assist with information necessary for the Utilization Review Team to obtain timely authorization(s) for services both during and after the patient’s hospitalization.
    • Identify patients who will benefit from the assistance of financial counselors and ensure the hospital’s financial counselors or outside contractors are consulted on the patient and follow-up to identify potential opportunities for financial assistance.
    • Work with the financial counselor team to obtain necessary information from the patient and/or family in order to determine eligibility for financial assistance.
    • Conducts a review of the progress toward discharge for assigned patients prior to daily discharge rounds. Attends discharge rounds prepared to discuss the barriers to discharge and anticipated needs.
    • Leads the discussion around discharge needs and barriers to discharge.
    • Develops and maintains working relationships with community agencies that provide services necessary for timely and effective discharge planning.
    • Keeps patient informed of their rights as a patient, including delivering the Important Message (IM) from Medicare. Communicates discharge requirements with patient and families. Identifies the need for patient notifications; including, HINN, HRR, and ABN. Works in conjunction with the RN Care
    • Coordinator anytime such a medical necessity notice is required for a patient.
    • Makes reports for suspected child abuse, elder abuse and domestic violence referrals pursuant to hospital and department policies and procedures.
    • Participates in a regular rotation of weekend and after-hours coverage in order to meet Department needs as determined by the Director of Case Management.
    • Possesses the knowledge base and counseling skills to effectively assist patients with advance directives and completes work on all assigned advance directive referrals in accordance with hospital policy
    • Perform other duties as they relate to social services as directed by the Manager of Care Coordination or the Director of Case Management.
    • Supports nThrive’s Compliance Program by adhering to policies and procedures pertaining to HIPAA, FDCPA, FCRA, and other laws applicable to nThrive’s business practices. This includes: becoming familiar with nThrive’s Code of Ethics, attending training as required, notifying management or nThrive’s Helpline when there is a compliance concern or incident, HIPAA-compliant handling of patient information, and demonstrable awareness of confidentiality obligations.


    • Bachelor’s degree in Social Work or related field and a Master’s degree.
    • 2+ years of experience as a Social Worker or completion of hospital Social Work internship.
    • Knowledge of Medicare and Medicaid payment rules, policies and regulations.
    • Demonstrated ability to navigate Internet Explorer and Microsoft Office.
    • Experience evaluating medical records and other health care data.
    • Experience exercise good judgment and tact in relating to third-party payers, physicians and patients.
    • Establish and maintain cooperative working relationships with Hospital staff and others contacted in the course of this position.
    • Ability to accurately complete tasks within established times.
    • Work independently and maintain confidentiality in all tasks performed.
    • Experience presenting information and respond to questions from small groups or one-on-one basis.
    • Experience ability to deal with problems involving several concrete variables in standardized situations.

    About nThrive


    Be Inspired. Ignite Change. Transform Health Care. 

    From Patient-to-PaymentSM, nThrive provides all the technology, advisory expertise, services, analytics and education programs health care organizations need to thrive in the communities they serve. Our colleagues share a united passion to help health care organizations strengthen their financial position, which translates to accessible, quality care for all. This passion fuels our drive to innovate and participate in community outreach through the nThrive CARES program. Our colleagues are encouraged to think differently and empowered to make a lasting impact that ensures our health care providers, and our world, are healthy and productive.


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