Social Worker I

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Perform psychosocial evaluations to recognize obstacles to discharge.

• Create tailored discharge strategies in collaboration with RN Case Managers, physicians, nursing staff, therapists, and other team members.

• Organize post-acute services such as home health, durable medical equipment (DME), transportation, community resources, and follow-up appointments.

• Engage with families, caregivers, and external providers.

• Ensure safe transitions to skilled nursing facilities (SNF), inpatient rehabilitation facilities (IRF), long-term acute care hospitals (LTACH), or home environments.

• Inform patients and families about available resources, benefits, and community programs.

• Assist in advance care planning conversations by providing non-clinical guidance.

• Support patients facing psychosocial challenges related to hospitalization, illness, or caregiving.

• Advocate for patient rights, preferences, and culturally sensitive care.

• Assess financial, housing, transportation, and social support requirements.

• Connect patients to community organizations, social service initiatives, and charitable resources.

• Collaborate with insurance case managers for authorization processes and benefit clarifications.

• Provide assistance with Medicaid, disability, and other assistance program applications as allowed.

• Participate in daily rounds, huddles, and care coordination meetings.

• Relay patient needs, barriers, and discharge readiness to the care team.

• Work alongside RN Case Managers on complex cases.

• Ensure timely and accurate documentation in electronic medical records.

• Adhere to CMS, Joint Commission, and hospital policies regarding discharge planning and patient rights.

• Contribute to efforts aimed at reducing readmissions, managing length of stay, and promoting value-based care initiatives.

• Note: This role does not involve providing psychotherapy, diagnosing mental health conditions, conducting clinical risk assessments requiring licensure, or performing licensed clinical interventions.

⛳️ Requirements

• Required - Master's Degree in Social Work.

• Required - Licensed Master Social Worker in Tennessee from the Tennessee Board of Social Workers (or licensed within 12 months).

• Preferred - Licensed Master Social Worker in Mississippi from the Mississippi Board of Examiners for Social Workers.

• Preferred experience in acute care, healthcare, social services, or community resource coordination.

• Strong preference for knowledge in discharge planning, community resources, and healthcare systems.

• Excellent interpersonal and teamwork skills within an interdisciplinary environment.

• Comprehensive understanding of community resources and the ability to connect patients and families to suitable services.

• Capability to collect, synthesize, and summarize relevant data for patient-centered decision-making.

• Strong verbal and written communication skills.

• Ability to foster constructive relationships and manage challenging, sensitive, or complex social situations.

• Organizational skills to effectively handle multiple tasks, caseloads, and projects with accuracy.

• Initiative, independent judgment, critical thinking, and problem-solving abilities.

• Ability to cultivate effective working relationships with physicians and healthcare professionals.

• Strong facilitation skills for patient/family meetings, team discussions, and care planning conferences.

• Proficient in Word, internet navigation, and electronic medical record systems.

• Good balance and coordination.

• Ability to respond swiftly to emergency situations.

• May be required to be on call for nights/weekends on a rotating basis.

🏝️ Benefits

• Opportunity to advance a career dedicated to helping others.

• Recognition as an employer of choice and a talent-rich organization.

• Family-oriented, team-focused, and Power of One culture.

• Commitment to high standards of care and unity.