Medical Social Worker, MSW - Center for Care Transformation

Location: Orion Building -6630 Orion Drive Fort Myers FL 33912

Department: Administration Services - CCT

Work Type: Full Time, Salaried

Shift: Shift 1/ to

Minimum to Midpoint Pay Rate: $57,345.60 - $74,547.20 / Annual

Summary

Care Coordination & Behavioral Health Referral

• Assess patients psychosocial, emotional, and social needs.
• Identify patients requiring behavioral health support and coordinate referrals to specialized behavioral health teams.
• Connect patients and families with community resources, post-acute care services, and support systems.
• Collaborate with care managers, interdisciplinary teams, and community providers to ensure continuity of care.
• Assist patients and families with navigating insurance, placement, and post-discharge resources.

Patient Advocacy

• Advocate for patients by facilitating communication between patients, families, physicians, and healthcare teams.
• Promote patient self-determination by providing information about care options and supporting participation in care planning.
• Support patients and families in understanding advanced directives and treatment choices.

Transition & Discharge Planning

• Participate in care planning to ensure safe and timely discharges.
• Assess patients capacity for self-care and the availability of caregivers.
• Provide education and resources to support patient goals and preferences.
• Monitor high-risk patients and coordinate interventions to prevent readmissions.
• Obtain approvals for post-acute services and provide patients/families with options.

Documentation & Compliance

• Maintain accurate and timely documentation of assessments, referrals, care conferences, discharge plans, and interventions in the EMR.
• Track patient outcomes and care coordination metrics as required.

Team Collaboration & Professional Development

• Work collaboratively with multidisciplinary teams to meet patient needs.
• Serve as a positive team member, assisting colleagues and supporting workflow.
• Participate in mentoring or onboarding of new staff or MSW students when applicable.
• Maintain professional boundaries and adhere to organizational policies.

Education:

Masters Degree in Social Work required.

Experience:

Minimum of 1-year clinical experience in medical or healthcare setting.

License:

Not required

Certification:

Not required

Other:

Communication and interpersonal skills, basic computer, analytical, grammar and spelling skills. Ability to effectively multi-task and prioritize responsibilities.

US:FL:Fort Myers