Social Worker - Specialist Care Management - LMSW/LCSW Required

Job Number: 1087465

Piedmont Atlanta Hospital - Atlanta, Georgia
Shift/Schedule: Full-time


ENTITY: Piedmont Atlanta Hospital

DEPT: Care Management

SCHEDULE: Full-time 

Responsible for assessing and managing psychosocial, resource, and discharge planning needs for the most challenging discharge planning issues and complex patient needs. (i.e. long length of stay, uninsured, underinsured, multifaceted medical, surgical, social needs, undocumented, repatriation to other state or country) throughout their stay. These patients require in depth coordination and / or have more barriers to an effective discharge than the average patient population. This position will work with those specific patient populations to promote the achievement of optimal clinical and resource utilization and facilitates appropriate lengths of stay. Analyzes current systems and variances to identify opportunities for improvement to reduce barriers to discharge. Provide data to support analysis / trends of Long Stay Patients. Works to promote quality of care and effective transitions planning through collaboration with all service team members, physicians, patients, external agencies and families. The Lead will follow the patients managed for 30 days post discharge to help reduce readmissions and ensure community resources, follow up, post-acute management or services are in place. Provides Social Work Practice coaching to assigned staff to promote the development of responsibility, skill, knowledge, and ethical standards in the practice of Social Work.


Master’s degree in Social Work is required.

Five (5) years of Social Work experience in an acute hospital setting.

Licensed Master Social Worker (LMSW) or a Licensed Clinical Social Worker (LCSW) in the state of Georgia.

Current working knowledge of community programs, resources, voluntary agencies, charity agencies, support groups, clinics, services to support patients post discharge and transition back to the community.

Current working knowledge of discharge planning, utilization management, care management, performance improvement and managed care reimbursement.

Certified Case Manager (CCM) and / or member of a professional association dedicated to the support and advancement of Social Work and / or Case Management preferred.

1. Manage a specialized patient case load from identification through to 30 days post discharge.
2. Acts as a resource and escalation point for the Care Management Team.
3. Review a patient’s situation and needs, determine if the patient meets the criteria for the Advanced Social Worker case load or the patient can be managed by the unit based teams with support and input from the Advanced Social Worker / other Care Management Leadership.
4. Serves as member of the Ethics Committee and as resource liaison for ethics consultations.
5. Ensures patient / family case conferences and meetings are conducted proactively and all members of the care team involved as needed. Document clear outcomes and follow up actions.
6. Identify needs for other specialist involvement or input, internal and external i.e. financial counselor, Department of Family Services, law enforcement, legal, compliance and risk management.
7. Negotiates with payers and agencies to achieve a cost effective alternative level of care.
8. Works in collaboration with Pharmacy where multiple medications are required to provide education.
9. Identify and secure authorizations for medication, or alternate resources / source of funding to ensure patients are discharged with medication management plan and medication is in place.
10. Attend weekly / scheduled Complex Length of Stay (LOS) meeting, provide report of case progress and follow-up, and formulate action items.
11. Input into / act as a resource in Length of Stay (LOS) meetings, identify where hospice or palliative care programs may be appropriate.
12. Ensures discharge plan is complete and that physician, nursing unit, and patient / family are informed.
13. Identify root causes in discharge planning processes or delays and data to support analysis and trends
of Long Stay Patients; Works in collaboration with the Care Management Director and other leadership to define and implement solutions.
14. Supports the development of training tools, resource guides and activities to improve skill sets and knowledge of resources for complex patients.
15. Provides teaching / learning sessions to improve the Care Management Teams knowledge in relation to challenging discharge planning.
16. Supports the training and onboarding of new Care Management team members.
17. Create a work environment for employees through team building, coaching, constructive feedback, work delegation, personal example and goal setting that encourages creativity, open dialogue on work issues, professional growth, and a consistent high level of performance: encourage and support the team’s decision making within their scope of responsibilities.
18. Must adhere at all times to Compliance policies and procedures and maintain sensitivity and confidentiality with patients’ medical record documentation, and all private health information used in Care Management processes.

• Must have conflict resolution skills.
• Must be a creative thinker and promote collaboration with post-acute agencies and providers.
• Strong analytical skills and data interpretation to promote improvement actions and measures.
• Ability to prioritize and manage multiple tasks simultaneously, to anticipate and proactively respond to an issue as needed in a dynamic work environment.
• Above-average ability to quickly research, target relevant clinical and social data from a medical record.
• Ability to develop and draft clear, succinct narrative in support of patient needs and action plans.
• Skill and ability to communicate effectively both verbally and in-writing.
• Maintain own professional growth, development, credentialing requirements to sustain relevant / leading practices and expertise enabling independent practice.
• Ability to work as a member of a high production team.
• Ability to work independently.
• Skill and ability to maintain focus, timeliness and accuracy with detail-oriented documentation production.
• Act as an enthusiastic coach and leader with demonstrated ability to mentor, train and develop employees and monitor performance.

The above information is intended to describe the general nature and level of work being performed by people assigned to this job. It is not intended to be an exhaustive list of responsibilities, duties and skills required of personnel so classified.

Diversity & Inclusion

At Piedmont Healthcare we embrace diverse ideas, perspectives, and skills to create a collaborative workplace where the best talent wants to succeed. We celebrate differences and recognize that they allow us to care for our community.

Excellence at Work

Piedmont is a certified Great Place to Work™-- a national designation based on employee feedback about trust, workplace culture and experience. In 2019, Forbes named Piedmont one of Georgia’s 10 best employers and the highest-ranked healthcare provider.

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