Social Worker- PRN, Lavonia GA

Social Worker – PRN, Lavonia GA

Company: St. Mary's Health Care System

The Social Worker, as part of a multidisciplinary team, identifies and initiates discharge planning to ensure timely transition of patients to post‑acute settings and supports patients, families, and staff across a range of needs including discharge planning, financial concerns, emotional issues, and psychosocial care. The role involves understanding social determinants of health, navigating community resources, and coordinating referrals to external agencies to facilitate smooth transitions and promote quality outcomes.

Part‑time

• Accurately assess psychosocial situations and develop appropriate treatment plans.
• Implement safe discharge/treatment plans in a timely manner to prevent avoidable inpatient stays.
• Explore options with patient/family and assist in decision‑making.
• Communicate discharge planning activities with interdisciplinary team daily via documentation and/or verbal reports.
• Maintain knowledge of community resources, eligibility criteria and referral processes.
• Refer cases to home health, hospice, skilled nursing facilities, DME companies and other OP services, and provide concurrent information as required.
• Document received referrals/consultations within 24 working hours.
• Apply social theories in clinical practice and demonstrate self‑awareness, overcoming personal biases.
• Provide advocacy and support to patients/families/staff while avoiding dysfunctional behaviors.
• Organize and prioritize caseload assignments efficiently.
• Demonstrate knowledge of Medicare, Medicaid and non‑governmental payer regulations.
• Identify and maintain working relationships with referral agencies.
• Follow HIPAA guidelines and CMS Conditions of Participation.
• Serve as a resource to the healthcare team and maintain good rapport.
• Approach conflicts constructively and assist in problem resolution.
• Engage in self‑directed learning and maintain confidentiality of patient information.
• Report hazards and unsafe practices to management immediately.
• Adhere to applicable laws, regulations, and St. Mary's policies and procedures.
• Attend team huddles and meetings when possible; otherwise review notes/minutes.

• Performs other duties as assigned.

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person‑centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.