Social Worker

Job Title : Clinical Social Worker – Acute Care Transition Team (ACTT)

Location : White Plains, NY

Unit Type : Social Work

Shift Length : 8 Hours

Guaranteed Hours : 37.5 hours per week

Charting System : EPIC

Compensation : $68 / hour

Position Summary :

We are seeking a dedicated and compassionate Clinical Social Worker to join our Acute Care Transition Team (ACTT). As an integral member of this team, you will focus on supporting patients with complex social determinants of health that impact their recovery process. The ACTT Social Worker will bridge the gap between outpatient and inpatient care, ensuring a smooth transition from the hospital to home. You will work closely with patients, families, and the healthcare team to ensure all aspects of care are met, from diagnosis and medication management to outpatient follow-up and community resource coordination.

Key Responsibilities :

• Collaborate with the ACTT to address the needs of high-utilizing acute care patients and those facing barriers to recovery due to social determinants of health.
• Facilitate communication between acute clinical settings (ED, inpatient, observation, labor & delivery, ambulatory surgery) and home environments.
• Coordinate outpatient follow-up, radiology and microbiology needs, and post-acute care assessments.
• Manage high-risk clinical follow-up and expedite outpatient testing, ED care, or direct admission / observation as needed.
• Assist patients and families in navigating the healthcare system and identifying available community resources and care linkages.
• Provide post-acute care phone calls to assess needs, satisfaction, and identify missed opportunities.
• Analyze and evaluate medical psycho-social programs to address post-acute care needs.
• Investigate insurance coverage for reimbursable services and inform patients / families about available resources and financial responsibilities.
• Work collaboratively with community agencies and the care team to ensure seamless care coordination.
• Transfer clinical concerns to relevant team members (ACTT clinician, nurse, etc.) as necessary to provide comprehensive care.

Education & Experience Requirements :

Additional Qualifications :

Salary : $68