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Social Worker - Coordinated Care

Candidate Experience site
Rome, GA Full Time
POSTED ON 4/5/2025
AVAILABLE BEFORE 6/4/2025

The Social Worker provides psychosocial assessments, intervention and/or treatment and discharge planning to patients and families to assist them in coping with their hospitalization, illness, diagnosis and/or life situation. He/she meets the continuing needs of patients post hospitalization. 

 

Essential Duties include: 

 

Carries out discharge planning for patients aging from neonate through geriatric. 

Assesses assigned patients to determine discharge planning needs. 

Discusses needs with patient/family and formulates discharge plan. 

Implements discharge plan. 

Follows up with patients/families on effectiveness of plan. 

Maintains appropriate and timely documentation in patient medical records. 

Documents in patient records every other day of progress of plan. 

Signs interdisciplinary discharge planning form. 

Provides social services throughout the Medical Center. 

Provides patient/family counseling. 

Arranges for patient home medications if needed. 

Makes referrals to local, state and federal agencies. 

Makes referrals to DFCS Adult or Child Protective Services. 

Provides patients/families with resource information. 

Makes Reach to Recovery referrals. 

Provides information on Advanced Directives. 

Sees patients in ECC or Outpatient Center and assists as needed. 

Assists patients in obtaining transportation to medical appointments. 

Follows patients admitted from nursing home. 

Provides statistical reports as needed. 

 

EDUCATION REQUIRED 

Graduate of BSW accredited program or Bachelor’s Degree in Social Work, Psychology or Human Services from and accredited institute 

EDUCATION PREFERRED  

Master’s in Social Work 

LICENSURES OR CERTIFICATIONS REQUIRED 

None 

LICENSURES OR CERTIFICATIONS PREFERRED  

CPR certification 

EXPERIENCE REQUIRED 

At least two years in human services or related field 

Knowledge of community agencies and resources 

EXPERIENCE PREFERRED 

None 

 

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