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AdventHealth

Integrated health system delivering whole-person care

Care Management Social Worker

Case Management & AdvocacyConfirmed live in the last 24 hours
Full-timeOcala, FL, USA$49.8k - $92.6kIn-person

About the Job

Requirements

  • A Master's in social work is required.
  • At least 2 years of social work experience is required.
  • A Clinical Social Worker License (LCSW) or Licensed Mental Health Counselor (LMHC) is required.

Responsibilities

  • Assess patients and families holistically for discharge planning needs in inpatient, observation, and/or emergency departments, including prior functioning, support systems, financial factors, and psychosocial factors, in a timely manner to avoid discharge-planning delays.
  • Review the medical record, including medications, history and physical, laboratory results, and progress notes, and incorporate clinical, social, and financial factors into the transition-of-care plan.
  • Develop discharge plans with appropriate contingency plans throughout the hospital stay to ensure timely care coordination and progression of care, arranging post-acute care services and facilities as well as community care for social needs.
  • Use technology and follow standard work and best practices to communicate with post-acute care services and facilities, ensuring patient-care information is communicated for continuity of care, medical records are complete, and discharge reconciliation is accurate.
  • Communicate with payors about patient needs for authorization for post-acute care as needed.
  • Participate in multidisciplinary rounds to review changes in patient status, progression and level of care, and discharge plans for assigned patients; identify resources necessary at discharge, ensure a timely transition, and escalate care delays to leadership as appropriate.
  • Communicate with and educate patients and families about the emotional, social, and financial impacts of illness, mobilize family and community resources to meet identified needs, and advocate for patient and family empowerment in making health care decisions and accessing services.
  • Assess readmitted patients for the patient’s and family’s perceived reasons for readmission.
  • Organize and facilitate patient and family care conferences with the multidisciplinary team.
  • Document discharge-planning evaluation, ongoing assessment, discharge plans, multidisciplinary rounds, barriers to progression of care, avoidable days, and patient and family needs according to standard work.
  • Provide patient and family advocacy and support patient choice and patient rights during hospitalization.
  • Perform other duties as assigned.

Desired Qualifications

  • Experience in an acute care setting is preferred.

About the Company

AdventHealth

Integrated health system delivering whole-person care

AdventHealth operates a nationwide network that provides whole-person health care across hospitals, physician practices, ambulatory surgery centers, outpatient clinics, home health, hospice, and digital tools. It coordinates care through an integrated system where care teams work across inpatient, outpatient, and at-home settings, supported by the AdventHealth app for scheduling, telehealth, and records. It differentiates itself with a mission-driven focus rooted in Christian heritage and a large, connected network designed to cover the full patient journey from hospital to home. Its goal is to extend the healing ministry of Christ by improving the health and prosperity of the communities it serves, offering accessible, coordinated care that addresses physical, mental, and spiritual well-being.

Company size
10,001+
Company stage
Grant
Total funding
$250K
Headquarters
Florida, United States
Founded
1973

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