Centers Health Care

Staten Island, NY

Social Worker - Transitional Care

Posted over 1 month ago

Job Description


Social Worker - Transitional Care

Revival Home Health Care is actively looking to hire a Social Worker.

The Social Worker is a core member of the Interdisciplinary Care Team (ICT) and works collaboratively with the I-SNP nurse practitioners to ensure the coordination and continuity of care as members move between different settings and levels of care to improve quality of care and reduce unnecessary hospitalization.

Essential Functions

  1. Develop and facilitate collaborative partnerships with all members of the ICT
  2. Participate in case discussion conferences related to hospital admissions, high-risk complex cases, and care planning
  3. Document relevant care transition planning information in the medical record according to department standards
  4. Communicate and collaborate with hospital staff on development of discharge needs/ plan
  5. Educate hospital staff of I-SNP Model of Care and clinical skill level of nursing facility to promote early discharge to nursing facility.
  6. Facilitate, address and resolve system problems impeding non-emergent diagnostic or treatment progress with the assigned population; proactively identifies and resolves delays and obstacles to coordinated care
  7. Coordinate communication with team and responsible parties (family) about transition process in accordance with department policies and procedures
  8. Develop care plans based on nurse practitioners plan of care for all new members and annually thereafter in accordance with MOC and department policies and procedures
  9. Monitors adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed
  10. Facilitate member access to health care services, identify network providers and work with the UM Department to obtain authorizations as needed
  11. Collaborates and assists care team in identifying level of care changes
  12. Receive, process and generate facility reports related to skilled level of care service days
  13. Monitors and report data on core MOC requirements
  14. Work closely with Management Team on development and implementation of methods, policies and procedures to improve the Departments efficiency and overall effectiveness
  15. Participates in the development of clinical pathways, best practice standards, competency processes


  • Bachelor's / Masters degree in social work.
  • 3-5 years of experience in a health care setting, preferably long term care.
  • Minimum of 3 years managed care experience required.
  • Knowledge of Medicare/Medicaid benefits and regulations required.


  • Excellent verbal and written communication and interpersonal skills
  • Ability to handle multiple tasks/projects concurrently
  • Strong skills in coordination of discharge planning, care plan development and implementation and follow up
  • Proficiency Microsoft Office applications (Word, Excel) and other data collection programs
  • Ability to demonstrate effective critical thinking and problem solving skills.

Position Type and Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday, 9am to 5pm. Some travel to hospitals and nursing facilities may be required


  • Staten Island, New York


About Us:

Centers Home Care is one of the largest home health care organizations in New York, providing every type of healthcare from Health aide to Physical Therapists, Registered Nurses, and more. Our network includes Alpine Home Health Care, Revival Home Health Care, InterGen Health, and Amazing Home Care. Whether you are a hospital planner arranging patient discharges, a rehabilitation patient in need of continuing care when you return home, or youre taking care of someone at home and need a little extra help, were here for you. We have the staff and most importantly, we have the expertise. We can solve your care needs, assist you with short or long-term equipment rental, and resolve insurance questions all with one call.


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