Care Coordination Social Worker MSW

Welcome to Saint Joseph Hospital, a 433-bed hospital founded in 1877 by the Sisters of Charity of Nazareth as the first hospital in Lexington, Kentucky. Led by Sister Euphrasia Stafford, the mission to provide compassionate care to the underserved is still carried out today. Saint Joseph Hospital holds over two dozen national ranks and recognitions and is recognized as a 2024 Best Place to Work in Kentucky. 

Saint Joseph is part of CommonSpirit Health, a non-profit, Catholic health system dedicated to advancing health for all people. With approximately 175,000 team members and 25,000 physicians and advanced practice clinicians. 

Our commitment to serve the common good is delivered through the dedicated work of thousands of physicians, advanced practice clinicians, nurses, and staff; through clinical excellence delivered across a system of 140 hospitals and more than 2,200 care centers serving 24 states.

Job Summary / Purpose

Works collaboratively with physicians, staff and other health care professionals within his/her Division to coordinate the care and service of selected patient populations across the continuum within the acute care setting. The role works collaboratively with patient, family, physician and other members of the health care team to achieve the highest quality clinical outcomes with the most cost effective use of available resources. The Social Worker supports responsibility for an interdisciplinary process to meet the psychosocial and transitional needs of the patient and family. The Social Worker is knowledgeable about various age-related care protocols and functions within their scope of practice. The Social Worker is an integral member of the health care team as well as the Divisional Care Management team. In addition, the position collaborates with the Divisional Care Management team on system-wide quality improvement/performance improvement initiatives.

Essential Functions

• Conducts a psychosocial assessment on identified priority patients in collaboration with family.
• Outline available strategies and services to assist in addressing psychosocial care needs, and to make recommendations as appropriate.
• Specialized screening tools may be used for the assessment such as Depression screen, Anxiety screen, Substance Abuse screen, Health Literacy screen, Mental Status screen, and Social Support screen as well as other specialized screens and evaluative tools.
• Develops individualized psychosocial case plans in collaboration with Case Manager -Acute Care based on assessment and in conjunction with other members of the Care Management team.
• Documents actions in medical record according to departmental guidelines and oversees process of exchange of information with other facilities/agencies adhering to legal mandates about confidentiality.
• Provides crisis interventions and psychosocial counseling services to restore patients and families to optimum social and psychological health based on their strengths and use of available resources.
• Provides factual information and materials to patients/families and others regarding programs end stage illnesses.
• Makes referrals promptly to appropriate agencies for services suitable to meet patients’ needs.
• Screens patients for financial assistance and helps clarify insurance benefits. Supports patients and families in their efforts to address and cope with the economic stress brought on by serious illnesses. Knowledgeable regarding financial resources.
• Assists patient and family in enrollment in needed programs and services.
• Assesses need for services through multidisciplinary rounds on patients and collaboration with physicians and other interdisciplinary team members.
• Consults with outside agencies in the delivery of individual/community care necessary to meet identified and agreed upon goals.
• Arranges for and coordinates a broad spectrum of discharge planning services for patients during their hospitalization.
• Collaborates with patient/family, physicians, and care management staff to determine patient’s post-discharge needs and plans.
• Provides patient/family with information on options/resources available and strategies for utilizing resources. Assists with all necessary referrals.

The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job. Employees may be required to perform other duties as assigned.

Education and Experience

• Master of Social Work (MSW) required. 

• Demonstrated experience in case management, discharge planning, and transfer coordination required.