The Social Worker Case Manager collaborates as part of a multidisciplinary team to initiate and support discharge planning from the time of admission, in compliance with Centers for Medicare & Medicaid Services (CMS) regulations. Responsibilities include assessing psychosocial needs, identifying barriers to discharge, coordinating community resources, managing patient cases, and maintaining timely documentation in the electronic medical record.The Social Worker Case Manager supports resource coordination and non-clinical discharge tasks in collaboration with RN Case Managers, but they lead the management of complex discharge needs requiring clinical judgment. They also facilitate safe and appropriate transfers to the next level of care,  including: skilled nursing facilities, inpatient rehabilitation, long-term acute care and long-term care, and arrange for post-acute services such as home health and hospice. This role is integral to ensuring timely, patient-centered discharge planning and continuity of care.
