This role supports patient care by coordinating discharge planning, assessing social determinants, and connecting families to community resources. The social worker advocates for patients and families, ensuring smooth transitions and addressing critical social needs.

Key Responsibilities:

Support comprehensive patient planning and post-discharge coordination to promote safe transitions of care. Screen and assess patients and families for social drivers of health such as food access, housing, transportation, financial concerns, and other resource needs. Serve as an expert resource regarding community-based social services and social determinants of health resources. Connect patients and families with appropriate community programs, services, and support systems. Refer patients to behavioral health when formal assessment or outpatient behavioral health services are appropriate. Provide education on food access and housing resources, and coordinate transportation to ensure medical care access. Assist patients and families during crises, providing understanding and counseling about medical impacts. Conduct financial assessments and provide appropriate referrals for financial assistance and community resources. Arrange in-home care, durable medical equipment, and other necessary services to support patients after discharge. Collaborate with physicians, nurses, case management, behavioral health professionals, and other members of the healthcare team. Advocate for patients and families while helping reduce barriers to healthcare access and continuity of care. Maintain appropriate documentation and follow organizational standards for social work services.

Qualifications:

Bachelor's degree in Social Work (BSW) required. California Licensed Clinical Social Worker (LCSW) license required. Experience with discharge planning, care coordination, patient advocacy, community resources, and social drivers of health is highly valued.

Preferred Skills:

Master's degree in Social Work (MSW) preferred. Three to five years of hospital social work experience preferred. Strong communication, assessment, organizational, and crisis-intervention skills are preferred.