Care Coordination Social Worker MSW Full Time Days

Welcome to Flaget Memorial Hospital, a 52-bed facility located in Bardstown, Kentucky. Founded in 1951 by the Sisters of Charity of Nazareth, Flaget Memorial Hospital is recognized as a 2023 Best Place to Work in Kentucky.Whether you are an experienced healthcare professional or working toward that, we invite you to experience Hello Humankindness with us! CHI Saint Joseph Health provides you with the same level of care you provide for others. Learn more about Flaget Memorial Hospital and its awards and recognitions here: Flaget Memorial HospitalOur 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 2200 care centers serving 24 states.Works collaboratively with physicians, staff and other health care professionals within his/her Division tocoordinate the care and service of selected patient populations across the continuum within the acute caresetting. The role works collaboratively with patient, family, physician and other members of the health care teamto achieve the highest quality clinical outcomes with the most cost effective use of available resources. TheSocial Worker supports responsibility for an interdisciplinary process to meet the psychosocial and transitionalneeds of the patient and family. The Social Worker is knowledgeable about various age-related care protocolsand functions within their scope of practice. The Social Worker is an integral member of the health care team aswell as the Divisional Care Management team. In addition, the position collaborates with the Divisional CareManagement 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 makerecommendations 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 asother specialized screens and evaluative tools.-Develops individualized psychosocial case plans in collaboration with Case Manager -Acute Care based onassessment 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 ofinformation with other facilities/agencies adhering to legal mandates about confidentiality.-Provides crisis interventions and psychosocial counseling services to restore patients and families to optimumsocial 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 stageillnesses.-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 intheir efforts to address and cope with the economic stress brought on by serious illnesses. Knowledgeableregarding 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 andother interdisciplinary team members.-Consults with outside agencies in the delivery of individual/community care necessary to meet identified andagreed upon goals.-Arranges for and coordinates a broad spectrum of discharge planning services for patients during theirhospitalization.-Collaborates with patient/family, physicians, and care management staff to determine patient’s post-dischargeneeds 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 workperformed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of alljob responsibilities required of employees assigned to this job. Employees may be required to perform otherduties as assigned.Education and ExperienceMaster of Social Work (MSW) required.Demonstrated experience in case management, discharge planning, and transfer coordination required.

Created: 2025-11-05