Senior Discharge Social Work Specialist; Associate Director of Social Work

Senior Discharge Social Work Specialist (Associate Director of Social Work)

Join to apply for the Senior Discharge Social Work Specialist (Associate Director of Social Work) role at NYC Health + Hospitals

This range is provided by NYC Health + Hospitals. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$/yr - $/yr

The Complex Discharge Escalation Team provides enterprise-level expertise, technical assistance, and structured support for high‑complexity cases.

Serving as a centralized source of consultation and operational support, the team will engage directly with facility-based staff to assess barriers, clarify clinical and regulatory requirements, coordinate with internal and external partners, and facilitate appropriate escalations to legal, governmental, or executive stakeholders.

The Senior Discharge Social Work Specialist serves as a senior partner to facility teams, bringing deep expertise in complex discharge planning, psychosocial assessment, behavioral health, legal coordination, and structural discharge barriers. The Specialist will play a key role in developing partnerships with external stakeholders, including post‑acute and community‑based care providers, city, state and federal agencies, legal entities, immigration offices, and vendors to resolve eligibility issues, secure services, and overcome regulatory and placement‑related challenges.

The position requires strong critical thinking, exceptional communication, adaptability, a solution‑oriented mindset with the ability to develop creative, patient‑centered strategies in the face of complex and evolving system constraints.

• Serves as consultant for the System on complex discharge planning, including identifying and resolving medical, behavioral, legal, and social barriers
• Provides leadership in Central Office in the development, coordination with facility leadership and Central Office partners to collaboratively overcome barriers, leading systemwide case conferencing escalation processes.
• Apply intensive troubleshooting and creative problem‑solving to generate viable discharge solutions for patients with unique and nontraditional care needs.
• Establishes enterprise‑level discharge planning social work related policies, methods, procedures, and program assignments and development; determines program priorities within the scope of program planning, particularly related to discharge planning.
• Develops, plans and administers discharge planning related strategies.
• Leads coordination of complex care plans involving adult protection, intellectual developmental disabilities, guardianship, housing, immigration status, legal involvement, or complex behavioral health presentations.
• Serves as the primary liaison for coordination with external agencies, including DSS, OMH, OPWDD, DOH, APS, and community‑based organizations.
• Builds and sustains partnerships with internal and external SNFs, assisted living programs, CHHAs, LHCSAs, housing providers, and other service networks to facilitate timely placements.
• Supports PASRR (Preadmission Screening and Resident Review) processes, including submission of documentation, support for denial reconsiderations, and coordination of fair hearings when appropriate.
• Oversees planning and documentation for repatriation cases, including coordination with international consulates, receiving facilities, transport vendors, and regulatory bodies.
• Partners with Legal Affairs and other internal stakeholders to address legal and regulatory discharge barriers, including capacity issues, court orders, and surrogate decision‑making.
• Participates in systemwide ALC reviews, and case conferences to resolve psychosocial and systemic barriers to discharge.
• Develops and implements department budget for complex discharge planning programming, overseeing contracts vendors as appropriate.
• Collaborates with Central Office partners (e.g., Behavioral Health, Office of Population Health, Legal Affairs, Housing for Health) to develop strategies that address key domains…