Transitional Care Social Worker

Transitional Care Social Worker

Essential Job Duties:

• Conduct social work assessments to evaluate the psychosocial needs, preferences, and goals of the patients. Actively participate in team meetings to develop care plans for participants.
• Implement and document social work interventions as outlined in each participant’s care plan. These interventions may include organizing necessary resources and services, assisting with care transitions, and providing individual or group counseling and case management.
• Collaborate with the primary care physician and other care team members to ensure seamless transitions of care across various settings, such as hospitals, skilled nursing facilities, and participants' homes.
• Initiate, coordinate, and facilitate care conference meetings to enhance care coordination among the care team, participants, and their support networks, including family and informal...