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Care Coordination Social Worker MSW

United States, Lexington Employment contract 26.70 - 39.71 USD / Hour · Job Posted June 16, 2026
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Job Description

As our Care Coordination Social Worker MSW, you will drive patient well-being and resource navigation, directly impacting the holistic care and successful transitions for hospitalized and emergency department patients. You will serve as a critical member of the Care Coordination and multidisciplinary healthcare teams, ensuring comprehensive support and linkage to essential resources. Every day you will be responsible for performing social work screenings and interventions for hospitalized and emergency department patients, in consultation with as needed and collaboratively with the Care Coordination and multidisciplinary healthcare teams. Your functions will include providing patient/family support and making appropriate referrals, conducting thorough social needs screenings, and facilitating referrals for financial or other identified resource needs. You will skillfully arrange family/patient representative meetings with the healthcare team as needed, assist in the post-acute placement of complex discharges, and engage appropriate agencies or community resources when patient's social needs are identified. To be successful in this role, you will possess strong social work assessment, intervention, and collaboration skills, with an unwavering commitment to patient advocacy, resourcefulness, and our organizational values. Your professional demeanor, dedication, and proactive approach are essential for fostering effective patient/family support, navigating complex social determinants of health, and ensuring seamless transitions of care for diverse patient populations.

Job Responsibility

  • Perform social work screenings and interventions for hospitalized and emergency department patients
  • provide patient/family support and make appropriate referrals
  • conduct thorough social needs screenings
  • facilitate referrals for financial or other identified resource needs
  • arrange family/patient representative meetings with the healthcare team as needed
  • assist in post-acute placement of complex discharges
  • engage appropriate agencies or community resources when patient's social needs are identified
  • plan for safe discharge and continuity of care
  • recognize and plan for unique needs of all ages, physically disabled, mentally ill, chronically ill, terminally ill, and vulnerable patients
  • provide patient/family support and health management education
  • identify and refer for social needs
  • manage complex social needs including abuse, neglect, trafficking, complex family issues, grief/bereavement support, adoptions, surrogacy, safe surrender, substance use and abuse, significant mental health or psychiatric concerns
  • address social determinants of health (e.g. housing and food insecurity, transportation)
  • participate in patient/family care conferences
  • facilitate patient decisions regarding post-acute care
  • maintain knowledge of community resources
  • coordinate mental health services and support
  • assist in referral and management of grave disability, palliative care/end-of-life, and hospice needs
  • coordinate discharge/transition planning for socially complex cases
  • provide community resource coordination including life-care planning and education on healthcare-related insurance/support programs
  • build and maintain community relationships

Requirements

  • Masters Other Social Work (MSW), upon hire
  • Licensed Social Worker: KY, upon hire
  • Master Social Worker: KY, upon hire

Nice to have

One year of healthcare experience

What we offer

  • medical
  • prescription drug
  • dental
  • vision plans
  • life insurance
  • paid time off
  • tuition reimbursement
  • retirement plan benefit(s) including 401(k), 403(b), and other defined benefits offerings
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