Care Coordination Social Worker

Job ID
Employment Type
Part Time
Hours Per Week
350 7th Street North


The Care Coordination Social Worker is responsible for effective and efficient utilization of hospital resources and assisting patients in receiving appropriate, high-quality hospital and post-hospital care and service in a timely manner while working to remove barriers that create delays. The Care Coordination Social Worker assesses patient and family psychosocial and discharges planning concerns relevant to medical treatment. Provides crisis intervention, emotional support, resource 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 Workers work closely with physicians, besides nurses, RN Utilization Review Navigators, discharge planning assistants, and associated clinical professionals to assist hospital patients in transitioning to the appropriate level of care.
  • Responds to the results of the RN Utilization Review Navigator discharge screening in order to identify patients who will have discharge planning needs. Accepts referrals for the same from physicians and nursing, as well as make independent assessments of patients who need discharge planning as their clinical course evolves.
  • The Social Worker determines those patients who will be followed by the Social Worker and delegates and oversees those who will be followed by the Discharge Planning Assistant.
  • The Social Worker works collaboratively with the RN Utilization Review Navigator on clinically complex patients as needed.
  • The Social Worker works collaboratively with the RN Utilization Review Navigator to ensure adherence to the appropriate length of stay, identifies barriers to safe discharge and takes appropriate steps to resolve barriers related to the discharge plan. When barriers persist, the Social Worker documents appropriate Avoidable Days in the UM module within Cerner.
  • The Social Worker confers daily with the RN Utilization Review Navigator regarding the discharge needs assessment conducted on all patients within 24 hours of admission and modified as the patient’s clinical condition and/or social needs to change throughout their hospitalization.
  • Confers daily with the attending physician and consulting physician to review and clarify progress towards the discharge and identified barriers to safe discharge for assigned patients.
  • Demonstrates high organizational skills, is empathetic and capable of multi-tasking in a high-stress clinical environment. Because families are often strained during hospitalizations, the 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.
  • Conducts initial assessments within 24 hours of admission on all patients identified to have discharge planning needs by assessing patients’ and families’ psychosocial needs, discharge planning preferences, in order to coordinate and facilitate expeditious discharge and post-acute care. Collaborates with and contributes to the interdisciplinary team’s plan of care. Identifies and utilizes appropriate resources to optimize effective, efficient, and safe discharge from the hospital.
  • Provides support to patients and families and links them to appropriate community resources.
  • Refers to patients/families and caregivers to appropriate resources regarding abuse/neglect/domestic violence, alcohol, and substance abuse. Performs appropriate clinical interventions 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 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, family, physicians, and other members of the interdisciplinary team to identify post-acute care options that meet patient needs and assist with information as necessary to ensure a safe discharge.
  • Keeps patients informed of their rights as a patient, including delivering the Important Message from Medicare (IMM), and observation notices to patients. Delegates to the discharge planning assistant as appropriate. Identifies the need for patient notifications including HINN notices and works in conjunction with the RN Utilization Review Navigator anytime such 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.
  • Possesses the knowledge base and counseling skills to effectively assist patients with advance directives and complete work on all assigned advance directive referrals in accordance with hospital policy.
  • Participates in a regular rotation of weekend coverage in order to meet the Department needs as determined by the Director of Case Management.
  • Performs other duties as assigned by the lead case manager, senior manager, and/or Director of Case Management.
  • Supports the nThriveCompliance Program by adhering to policies and procedures pertaining to HIPAA, FDCPA, FCRA, and other laws applicable to nThrive business practices. This includes: becoming familiar with the nThrive Code of Ethics, attending training as required, notifying management or nThrive Helpline when there is a compliance concern or incident, HIPAA-compliant handling of patient information, and demonstrable awareness of confidentiality obligations. 


  • Master’s degree in Social Work from an accredited school of Social Work required.
  • Strong written and verbal communication abilities.
  • Ability to effectively use Microsoft Word, Excel, and Outlook required.
  • Ability to evaluate medical records and other healthcare-related data.
  • Ability to exercise good judgment and tact in relating to third party payers, physicians, and patients.
  • Ability to work independently, delegate effectively, and works as a member of the overall care coordination team.
  • Ability to establish and maintain effective and cooperative working relationships with hospital staff and others contacted in the course of this position.
  • Ability to accurately complete tasks within established timeframes.
  • Demonstrated ability to effectively prioritize multiple tasks and deadlines.
  • Ability to maintain confidentiality in all tasks performed.
  • Excellent problem-solving skills.
  • Demonstrated ability to effectively present information and respond to questions from small groups or on a one-to-one basis.
  • Strong presentation skills.

Preferred Skills

  • 1+ years of experience as a Social Worker of completion of a hospital Social Work internship strongly preferred.
  • Knowledge of Medicare and Medicaid payment rules, policies and regulations.

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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