Post Acute Care Liasion (MSW) - Care Management

Job Number:

33395

Location:

Phoebe Putney Memorial Hospital

Street Address:

417 W 3rd Ave

City, State:

Albany, Georgia

Zip Code:

31701

Department:

PPMH CARE MANAGEMENT

Shift:

Days

Job Type:

Full time

Posted Date:

2026-01-13

Job Description Summary:

The Social Worker (MSW) provides a broad spectrum of professional SW services and functions. Demonstrates proficiency, autonomy, and accountability in assuring patient care management needs are met from a well-coordinated interdisciplinary and collaborative perspective with the RN Care Manager and other members of the healthcare team. Utilizes professional clinical social work skills to screen and assess patient/family needs for complex discharge planning, placement, education, referrals, and psycho-social assessment and counseling needs to establish plans for the effective management of the patient/family. The MSW must be able to perform work using accepted SW standards of practice, and demonstrate skills and knowledge necessary to provide intervention appropriate to age, education level, and capabilities of the patient served. The MSW role includes being proactive in planning, implementing, and evaluating patient care across the continuum that optimizes quality, patient/family satisfaction, utilization, and cost. Complies with related Federal, State, Payer and regulatory requirements.

Description:

Job Summary:

Qualifications:
Education: Master's Degree in Social Work (Required)
Work Experience: 1 or more years working in an Acute Care setting or related Community Service Organization. (Required)
Licenses and Certifications: Licensed Clinical Social Worker (Preferred)

Essential Functions:

• Serve as a liaison between skilled nursing, rehab, swing bed, home health providers, payers and regulatory agencies to facilitate safe and timely discharges.
• Ensure safe, expeditious, and timely transition of patients to the next level of care
• Inform patients of choice of post-acute providers as required by Medicare Conditions of Participation, providing lists of SNFs, home health agencies and hospice facilities as evidenced by documentation in the medical record.
• Facilitate patient involvement in his or her own care by providing education and obtaining the necessary information required for successful transition to the appropriate post-acute level of care.
• Complete detailed and comprehensive assessments using data from the patient, clinicians, medical records, diagnostics, medications, and functional abilities to ensure clinical needs of the patient will be fully met in the next level of care.
• Represent a clinically accurate picture of the patient to allow receiving facility to provide high quality care and to meet clinical guidelines as established for admission to the facility.
• Drive reduction in 30-day readmissions –hospitalizations by working closely with Care Managers, physicians, other clinicians and other receiving facilities to ensure proper placement.
• Maintain consistent professional development skills, through relationship building and a team concept, while applying knowledge and skills necessary to provide appropriate continuous care to patients.
• Collaborate with and complement the clinical members of the patient’s healthcare team, communication in an assertive, yet responsive way.
• Effectively prioritize, assess, plan, coordinate, and evaluate the care of patients and their families to achieve quality and cost-effective outcomes.
• Maintain knowledge of evolving healthcare systems, including but not limited to, funding sources, third party reimbursement, contractual arrangements, managed care, continuum of care issues, disease management, and clinical guidelines.

Additional Duties:

• Adheres to the hospital and departmental attendance and punctuality guidelines.
• Performs all job responsibilities in alignment with the core values, mission and vision of the organization.
• Performs other duties as required and completes all job functions as per departmental policies and procedures.
• Maintains current knowledge in present areas of responsibility (i.e., self education, attends ongoing educational programs).
• Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.
• Demonstrates competency at all levels in providing care to all patients based on age, sex, weight, and demonstrated needs.
• For non-clinical areas, has attended training and demonstrates usage of age- specific customer service skills.
• Wears protective clothing and equipment as appropriate.