Case Manager Social Worker

LifeBridge Health, Inc. seeks a Case Manager Social Worker to support patients and families across the care continuum. In this role, you will conduct comprehensive psychosocial assessments, develop and implement discharge and care plans, and coordinate services with physicians, nurses, and community providers. You will connect patients to community resources, address social determinants of health, and advocate for safe transitions of care. Working in a patient-centered, mission-driven environment, you will contribute to quality, cost-effective outcomes while supporting diverse populations and continuous improvement.

Responsibilities

• Perform comprehensive psychosocial assessments for diverse patient populations
• Develop, implement, and update individualized care and discharge plans
• Coordinate services with physicians, nurses, and interdisciplinary team members
• Arrange post-acute services, including home care, rehab, and community programs
• Identify and address social determinants of health impacting patient outcomes
• Connect patients and families to community and financial assistance resources
• Advocate for safe, timely transitions of care across settings
• Document all assessments, plans, and interventions in the EHR accurately and timely
• Monitor patient progress and adjust plans to support quality, cost-effective care
• Participate in quality improvement initiatives and interdisciplinary case conferences

Required Skills

• Psychosocial assessment
• Care coordination
• Discharge planning
• Utilization management
• Clinical documentation
• Motivational interviewing
• Crisis intervention
• Interdisciplinary collaboration
• Knowledge of community resources
• Electronic health record (EHR) systems