Social Worker II AHWFB

Step into a role where your compassion, clinical skill, and advocacy make a daily difference. As a Social Worker II, you’ll be a trusted partner to patients and families navigating complex health journeys—leading discharge planning and care coordination, connecting people to the right community resources, and collaborating across a multidisciplinary team to drive positive outcomes. In this fast‑paced hospital environment, you’ll be the voice for psychosocial needs that shape health, and the guide who helps patients move confidently to their next step in care.

Essential Functions

• Provide comprehensive social work services to patients and families, with a focus on complex discharge planning and seamless care coordination across the continuum of care.

• Identify patients who would benefit from case management interventions based on an initial screening of discharge needs.

• Conduct thorough interviews with patients/families and perform objective evaluations to assess psychosocial, environmental, and support needs.

• Complete psychosocial assessments per departmental and professional standards, identifying emotional, social, and environmental factors related to diagnosis, treatment, and life circumstances.

• Formulate and implement individualized psychosocial treatment plans using appropriate modalities (e.g., crisis intervention, individual and family therapies, grief and bereavement counseling).

• Initiate timely internal and external referrals tailored to each patient’s needs, ensuring access to community services and supports.

• Advocate for unmet patient/family needs and remove barriers to efficient, effective care progression.

• Collaborate closely with the multidisciplinary team to develop and execute evidence‑based discharge plans that advance patient progression.

• Maintain current knowledge of federal, state, and local regulations, as well as payer and reimbursement practices that impact care planning.

• Guide patients and families through options for post‑discharge care (e.g., home health, SNF, rehab, community programs), facilitating informed, safe transitions.

• Coordinate patient and family care conferences as needed to align goals, clarify plans, and resolve concerns.

• Communicate clearly with hospital staff regarding psychosocial issues that affect health status, engagement, and treatment adherence.

• Document all assessments, plans, interventions, and outcomes in the Electronic Medical Record in accordance with departmental reporting standards.

• Demonstrate competence in age‑ and developmentally appropriate care, build positive work relationships, and thrive amid multiple interruptions in a rapidly changing healthcare environment.

Education & Experience (Licensure/Certification)

• Master’s degree in Social Work (MSW) from a program accredited by the Council on Social Work Education (CSWE).

• Clinical licensure (or provisional status) desirable.

• Certification as an Accredited Case Manager (ACM‑SW) preferred.

• Prior social work experience in a healthcare setting desirable.