Job Description

Social Worker – Care Coordination

Why UT Southwestern?  

With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. At UT Southwestern, we invest in you with opportunities for career growth and development that align with your future goals and help to provide security for you and your family. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more that are all available on the day you start work. UT Southwestern is honored to be a Veteran Friendly work environment that is home to approximately 800 veterans.  We value your integrity, dedication, and the commitment you’ve made to our country.  We’re proud to support your next mission.  Ranked by Forbes as one of the Top 10 National Employers, we invite you to be a part of the UT Southwestern team where you’ll discover teamwork, professionalism, and consistent opportunities for growth.   To learn more about the benefits UT Southwestern offers, visit 

Job Summary

The social worker Care Coordinator is a member of the Care Coordination Department (a Hospital department) who educates the healthcare team and physicians about psychosocial issues and any identified patient/family problems as well as strategies to address the issues. 

The individual in this position, in conjunction with RN Care Coordinators, has overall responsibility to assess the patient for transition needs including identifying and assessing patients at risk for readmission. This position will conduct complex psycho-social assessment and intervention to promote timely throughput, facilitate a safe discharge and prevent avoidable readmissions.

This position integrates national standards for case management scope of services including:

Care Coordination- A process whereby screening/identification, assessment, planning, sequencing of care and communication, when effectively integrated, ensure and advance the plan of care to support successful transitions.

Compliance- Knowledge related to federal, state, local hospital and accreditation requirements that impact scope of services to include,

Centers of Medicare and Medicaid Services (CMS) Condition of Participation.  Transition Management- Planning that begins at the time of the initial patient encounter (preadmission, admission, emergency department, etc.) and is reevaluated and adjusted throughout the patient’s hospital stay. Care Coordinators (both SW and RN) will arrange/ensure all elements of the transition plan are implemented and communicated to key stakeholders including, but not limited to, the health care team, patient/family/ caregiver, and post-acute providers. 

Care Coordinators will convey all necessary information for continuity of care and patient safety, verify receipt and provide a venue for additional questions and/or information requests/needs Experience and Education  Two (2) years’ hospital experience preferred Social Worker LMSW (Licensed Master Social Worker in the State of Texas) required

Experience and Education

• Two (2) years’ hospital experience preferred
• Social Worker LMSW (Licensed Master Social Worker in the State of Texas) required

Job Duties

• Screens and evaluates high risk patients for discharge planning needs. 
• Consults with attending physicians and members of the healthcare team regarding any identified psychosocial issues and/or care transition barriers. 
• Recognizes that the transition process is collaborative with the multidisciplinary team to include the patient/family and assists with executing the plans and interventions to facilitate the hospital stay and manage length of stay and reassesses as care needs change. 
• Facilitates patient care conferences as indicated, to include complex cases to proactively assist with establishing a safe and effective discharge plan. 
• Implements the transition of care plan to the next level through appropriate service referrls and assures that the patient is given choice in regards to agencies and services. 
• Assists with adoptions, abuse and neglect cases, including assessment and investigation, intervention and referral as appropriate to local, state, and/or federal agencies, as indicated. 
• Educates and provides information and resources to patients and families regarding the availability of community resources.  
• Interprets patient and family needs and provides information concerning availability and limitation of resources. 
• Maintains open communications with community agencies to appropriately assist in referring and meeting patient needs.
• Maintains knowledge of payor benefits, hospital and community resources, and regulatory standards to ensure informed decision making, continuity of care, and desired outcomes (i.e. medical, medical cost, quality of life, and patient satisfaction).
• Maintains chronological notes, clinical charts, statistical data, or case histories for each patient with respect to social problems, adjustments for patient and family involvement, and actions taken or planned.
• Duties performed may include one or more of the following core functions: 

(a) Directly interacting with or caring for patients;

(b) Directly interacting with or caring for human-subjects research participants;

(c) Regularly maintaining, modifying, releasing or similarly affecting patient records (including patient financial records); or

(d) Regularly maintaining, modifying, releasing or similarly affecting human-subjects research records.

• Performs other duties as assigned.

This position is security-sensitive and subject to Texas Education Code §51.215, which authorizes UT Southwestern to obtain criminal history record information. UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. To learn more, please visit: 

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