Care Mgr - Social Wrkr - Inpat & Ed

Brattleboro Memorial Hospital /

Southern Vermont Health Services Corporation

Job Description

Job Title: Social Worker (Inpatient & ED)

Job Code: 1027

Hours: 40/week

FTE: 1.00

Weekend Schedule: Saturday Rotation (once monthly)

Holiday Schedule: 

Call Schedule: No call schedule 

FLSA Status: Exempt

Department Name: Care Management

Department Code: 7700

Location: Brattleboro, Vermont

JOB SUMMARY:

In accordance with Care Management, Discharge Planning, and Social Service policies, the Care Manager performs comprehensive psychosocial and functional assessments, care coordination, and discharge planning to ensure timely, safe, and patient-centered transitions of care. The Care Manager monitors and coordinates the plan of care; identifies and evaluates patients’ individual medical, psychosocial, and social determinants of health needs; and assists patients, families, and healthcare professionals in addressing those needs and developing appropriate plans for post-hospital care. The Care Manager proactively links patients to community-based services and supports to reduce avoidable hospital days and readmissions.

This role provides education, advocacy, counseling, and resource coordination, addressing both clinical and psychosocial barriers that delay discharge and impact long-term wellness. The Care Manager serves as a resource to patients, families, hospital staff, medical providers, and community partners by facilitating timely access to community services, coordinating complex post-acute care needs, and resolving non-clinical barriers to discharge. Through early intervention, interdisciplinary collaboration, and effective community linkage, the Care Manager plays a key role in reducing length of stay, improving emergency department flow, optimizing inpatient throughput, and promoting optimal patient outcomes.

KEY RESPONSIBILITIES:

• Conducts comprehensive assessments addressing medical, psychosocial, functional, and SDOH needs to identify barriers to discharge and long-term stability.
• Collaborates with the interdisciplinary team to develop, implement, and evaluate individualized plans of care and discharge plans.
• Provides patient and family with available resources and post-discharge care options.
• Coordinates with insurance payers, post-acute providers, and community agencies to ensure appropriate level of care and resource access.
• Serves as liaison and advocate for patients and families, ensuring communication of patient preferences and goals.
• Utilizes critical thinking to evaluate patient status, progress, and potential for safe discharge.
• Provides psychosocial support and crisis intervention for patients and families experiencing acute stress, loss, or complex medical and social issues.
• Identifies and reports suspected abuse, neglect, or exploitation per regulatory requirements.
• Participates in daily interdisciplinary rounds and huddles to support real-time discharge planning and barrier resolution.
• Collaborates with external partners (e.g., primary care providers, home health, skilled nursing, behavioral health agencies) to coordinate and facilitate continuity of care.
• Documents assessments, plans, and interventions in the electronic health record (EHR) timely and accurately.
• Participates in quality improvement initiatives, data collection, and departmental performance activities.
• Demonstrates knowledge of community resources, entitlement programs, and financial assistance options.
• Adheres to standards of professional practice and ethical conduct.
• Performs other duties as assigned.

DEPT. SCOPE OF SERVICE:

The Care Management Department provides hospital-wide support in discharge planning, care coordination, utilization management, and social services. Collaborates with patients, families, medical staff, and community providers to ensure a seamless transition to home or another care environment. The department integrates assessment of SDOH, behavioral health, and community resource needs into discharge planning and post-acute care coordination.

QUALIFICATIONS:

Education: 

• Bachelor’s degree in social work required. Master’s in social work preferred.

Experience: 

• Minimum of two (2) years of experience in care management, discharge planning, or related field preferred.
• Case Management Certification preferred.
• Experience in acute care, public health, or behavioral health is strongly preferred.

Licensure/Certification: 

• Vermont LSW required (LICSW or MSW preferred).
• Must remain current with continuing education and licensure requirements.

Skills & Abilities:

• Strong communication, critical thinking, and problem-solving skills.
• Strong critical thinking and psychosocial assessment skills
• Ability to work independently and collaboratively within an interdisciplinary team.
• Proficiency with EHR care management documentation and data tracking.
• Knowledge of medical terminology, discharge planning, and community resource navigation.
• Excellent written/verbal communication for coordination with multidisciplinary teams and payers.
• Ability to manage multiple priorities in a dynamic environment.
• Compassionate, patient-centered approach to care.

OSHA CATEGORY

Category I: Tasks that involve exposure to blood, body fluids, or tissues require adherence to Universal Precautions per Bloodborne Pathogen standards.

PHYSICAL DEMANDS & WORK ENVIRONMENT:

Physical demands and environmental conditions consistent with those of a hospital-based professional role as outlined in hospital policy.

• On-the-job time is spent in the following physical activities.
• Standing - Up to 1/3
• Walking - Up to 1/3
• Sitting - 2/3 or more
• Talking or Hearing - 2/3 or more
• Use of hands to finger, handle or feel - Up to 1/3
• Pushing/Pulling - None
• Stooping, kneeling, crouching or crawling - None
• Reaching with hands and arms - Up to 1/3
• Tasting or smelling - None

This position requires that weight be lifted or force be exerted.

• Up to 10 pounds - 2/3 or more
• Up to 25 pounds - 1/3 to 1/2
• Up to 50 pounds - Up to 1/3
• Up to 100 pounds - None
• More than 100 pounds - None

This position has special vision requirements.

• Close Vision (clear vision at 20 inches or less)
• Color Vision (ability to identify and distinguish colors)
• Ability to Adjust Focus (ability to adjust eye to bring an object into sharp focus)

WORK ENVIRONMENT

This position requires exposure to the following environmental conditions.

• Wet, humid conditions (non-weather) - None
• Work near moving mechanical parts - Up to 1/3
• Fumes or airborne particles - Up to 1/3
• Toxic or caustic chemicals - Up to 1/3
• Outdoor weather conditions - None
• Extreme cold (non-weather) - None
• Extreme heat (non-weather) - None
• Risk of electrical shock - None
• Work with explosives - None
• Risk of radiation - None
• Vibration - None
• The typical noise level for the environment is:
• Very Quiet
• Quiet
• Moderate Noise
• Loud Noise

Hearing

• Ability to hear calls
• Ability to hear instructions from physician/department staff/others

EEO/ADA STATEMENT

Brattleboro Memorial Hospital provides equal employment opportunities to all applicants and employees and strictly prohibits any form of discrimination or harassment based on race, religion, age, color, sex, disability status, national origin, genetics, sexual orientation, protected veteran status, gender expression, gender identity, or any other characteristic protected under federal, state, or local law.

In compliance with the Americans with Disabilities Act (ADA), BMH provides reasonable accommodations for qualified applicants or employees with disabilities, unless such accommodation would create undue hardship. Requests for reasonable accommodation may be made through Human Resources.

Compensation Disclosure in Accordance with Vermont Act 155

In compliance with Vermont Act 155, Brattleboro Memorial Hospital provides the compensation range for this position in good faith. The listed range represents the pay scale reasonably expected for a successful candidate based on factors such as relevant experience, education, internal equity, and market competitiveness. Final compensation will be determined during the hiring process.