Care Coordination Social Worker BSW

Essential Functions

Providing developmentally appropriate care for all populations served: plan for the safe discharge and continuity of care, recognize and plan for the unique needs of all ages, the physically disabled, mentally ill, chronically ill, terminally ill, and vulnerable patients.

Advocacy and education: patient/family support; patient/family health management education; healthcare team and community education; case/care management/coordination education and training; social needs identification and referral.

Complex social needs management: social needs screenings; determination of patient functioning and availability of support systems; support in addressing social needs and making related referrals; escalation of identified cases involving abuse, neglect, trafficking, complex family issues affecting care, grief/bereavement support (individual and group), adoptions, surrogacy, safe surrender, substance use and abuse, and significant mental health or psychiatric concerns; addressing, managing, and referring resources related to social determinants of health (e.g. housing and food insecurity, transportation).

Patient/Family Care Conferences: interdisciplinary care communication/coordination related to continuity/transitions of care planning and management; share in responsibility for identifying appropriate decision makers if the patient is unable or without capacity.

Discharge/Transition Management: as member of Care Management/Coordination team, facilitation of patient decisions and communications regarding post-acute care; professional responsibility for knowledge of community resources related to social work scope of practice; maintaining appropriate up-to-date resource lists; education for patients/families about availability of community resources; mental health service and support coordination;  assistance in referral and management of grave disability, palliative care/end-of-life, and hospice patient/family needs; interventions, management, and coordination of discharge/transition planning for socially complex cases.

Community Resource Coordination: life-care planning; consultation on healthcare resources; team and patient education regarding various healthcare-related insurance/support programs (e.g. CCS/Medicare/Medicaid/SSI); building and maintaining community relationships to address needs of patients experiencing homelessness and to meet other social needs.

Documentation: thorough, accurate, and timely documentation of, but not limited to, screenings, care recommendations, patient, family, and collateral contacts, discharge/transition planning, and referrals.

Performance & Outcomes Management: understanding and application of federal/state/local regulatory agency guidelines, The Joint Commission standards, and other regulatory and accreditation requirements;  implement evidence-based practices; support organizational financial performance, length of stay, cost per case, readmission prevention efforts and revenue cycle goals.

Provide support and social work services to outpatients if directed by Care Coordination leaders.

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.

Minimum Qualifications

Bachelor of Social Work (BSW)

One year of healthcare experience (preferred)

Welcome to Saint Joseph London, a 150-bed regional hospital founded in 1926. Located on a 52 acre healing environment, Saint Joseph London offers private patient rooms that overlook a small lake and healing garden and has been recognized as a Best Place to Work in Kentucky for five years in a row (2020-2024). 

CHI Health Saint Joseph is part of CommonSpirit Health, a non-profit, Catholic health system dedicated to advancing health for all people. With approximately 175,000 team members and 25,000 physicians and advanced practice clinicians.

Our commitment to serve the common good is delivered through the dedicated work of thousands of physicians, advanced practice clinicians, nurses, and staff; through clinical excellence delivered across a system of 140 hospitals and more than 2,200 care centers serving 24 states.