Make a meaningful difference every day by supporting patients with the most complex psychosocial and care‑transition needs. As a Complex Inpatient Medical Social Worker, you will serve as an expert resource, guiding patients, families, and clinical partners through challenging circumstances while ensuring safe, effective, and timely transitions across the care continuum. This highly skilled role is ideal for an experienced social worker who thrives in a collaborative, fast‑paced inpatient environment and is passionate about advocacy, care coordination, and improving outcomes for vulnerable populations.

Major Responsibilities:

• Provides care management/social work services to Complex patients, families, and individuals including perming thorough patient psychosocial assessments, screening, determination of needs evaluation, appropriate interventions and follow up, and discharge planning. Implements targeted interventions and patient-family centered care plans to achieve optimal health outcomes. Care plans are substantiated by assessment as appropriate to the needs of the patient/client system and consistent with available resources and payer network. Collaborates and negotiates effectively with socially complex patients, family and the clinical team while striving to achieve patient and organizational goals regarding care needs, choices, and satisfaction during discharge planning and care transitions.

• Provide continuity of care and discharge planning services for socially complex patients compliant with regulatory standards. Offers coordinated, relevant options and services based on assessed needs to ensure patient, families, and the healthcare team are informed and prepared to proceed with accountabilities in a timely manner. Participates in the communication processes to facilitate smooth transitions for patients, families, and staff during patient transfers.

• Provides advanced care management guidance and mentorship to frontline care management team members fostering a culture of excellence and continuous improvement. Lead initiatives aimed at enhancing care quality, patient safety, and overall healthcare delivery efficiency. Creates relationships with community resources to facilitate referrals for Complex patients and is viewed as an expert with area resources.

• Initiates internal and external referrals to ensure timely progression of care and transitions for socially complex patients. Documents discharge planning interventions and utilization review activity according to department and organization standards in a timely manner. Performs and documents accurate and timely concurrent and retrospective reviews for socially complex patients based on approved criteria by department standards. Advocates for patients and their families to ensure their voices are heard and their needs are met within the healthcare system while optimizing the utilization of hospital resources ensuring cost-effective care delivery and adherence to regulatory guidelines.

• Communicates effectively with the healthcare team regarding socially complex patients. Partners with RN Care Manager and unlicensed support personnel to effectively establish and implement a safe plan of care. Serves as a leader of the multidisciplinary rounds and work closely with clinical team members, hospital departments and ancillary services to identify and resolve barriers to discharge, expedite care delivery to avoid delays in timely service provision, and implement and report on care coordination and discharge planning.

• As an expert in care management of socially complex patients, collaborates and leads discussions with managers, physicians, medical directors, advisory groups, and treatment teams for issues related to physician practices and best practices for patient care plans. Refers cases to physician advisors as needed to ensure efficient progression of care, accurate status, and compliance with regulatory guidelines. Maintains knowledge of healthcare regulations, reimbursement issues, impact on length of stay and community-based resources. Delivers CMS regulatory notices within CMS established timeframes, as appropriate based on-site guidelines.

• Develops and maintains productive relationships with community-based agencies, particularly those serving socially complex patients. Represents Advocate Health in a positive manner, working collaboratively, internally and externally to meet patient and family needs. Collaborate with Advocate Health Ambulatory Care Management and Continuing Health to achieve mutual goals and outcomes. Responsible for staying current on changes in the healthcare landscape as it pertains to post-acute placement venues and the offerings of various venues. Responsible for updating the team and the SharePoint site with current information.

• ​​Serves as a leader in the multi-disciplinary health care team to develop safe and timely coordination of care including but not limited to post-acute placement, palliative/hospice service lines, medical equipment, home healthcare, outpatient follow up, mental health resources, and other community resources. Advocates for patient involvement in the plan of care. Initiates and coordinates interventions with the activities of other members of the health care team. Coordinates and leads Care Conferences for Complex patients. Serves as a leader to follow up with internal partners, such as financial advocates, Patient Access, Level II assessors, and other multi-disciplinary teammates to drive optimal results and reduce delays in patient throughput

• Maintains up-to-date knowledge of community resources, legislation, and regulations impacting health care delivery and educating patients and families on these issues as appropriate. Provides resources to patients and families to ensure a timely discharge and to provide an appropriate link with post-acute care providers and services. Provides support and connection to additional services such as bereavement and loss, ethical issues, advanced directives, and end of life issues. Connects patients to appropriate agencies on issues of suspected abuse and neglect, domestic violence, guardianship, and other social matters. Collaborates with community agencies and institutions to plan continued care and to coordinate interventions. Provides resources and education to patients and families regarding appropriate resources and access to community social services. Provides education to patients/families regarding Advance Directives for health care decision-making. Assists with execution of these documents as appropriate. Participates in legal proceedings as necessary to secure legal decision-makers.

• Manages the progression of patients stay with the goal of optimizing the LOS and ensuring appropriateness of assigned Level of Care. Manages the patient’s care across the continuum to decrease unnecessary readmissions. Manages and coordinates patient care within an ACO environment to help facilitate patient outcomes through in network care coordination. Accountable for site specific KRA goal achievement as it relates to Care Coordination across the continuum. Participates in the orientation of new staff and/or education of social work students. Aggregates, analyzes, interprets and reports data on patient outcomes and resource utilization. Facilitates reporting of utilization monitoring and review activities to relevant committees and stakeholders

Minimum Job Requirements

Education

• Master’s Degree in Social Work

Certification / Registration / License

License

• NC & GA Division: No license required

• Maintains professional standards and responsibilities for his/her own professional practice according to accreditation, hospital, system, state and NASW Standards and Code of Ethics. Completes all required continuing education to maintain licensure and increase knowledge within area of practice specialty.

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Certification:

• Accredited Case Manger SW (ACM-SW) certification issued by the American Case Management Association (ACM) needs to be obtained within 2 years, or

• Certified Case Manager (CCM) issued by the Commission for Case Manager Certification (CCMC) needs to be obtained within 2 years, or

• Certified Social Worker in Health Care (C-SWHC) issued by National Association of Social Workers to be obtained within 2 years

Experience

• 3 years of hospital care management experience.

Knowledge / Skills / Abilities

• Ability to prioritize and organize work.

• Effective communication skills.

• Utilization of critical thinking and timely decision making.

• Ability to navigate the electronic health record.

• Basic utilization of MS Office products.

• Knowledge of Medicare A and B guidelines.

• Knowledge of managed care program requirements/implications.

• Ability to apply elements of utilization management programs.