Social Services Coordinator

Essential Functions:

• Conducts comprehensive biopsychosocial and social needs assessments, identifying social, emotional, financial, behavioral, and environmental factors that impact health outcomes and care plan adherence.
• Utilizes motivational interviewing and other engagement strategies to build rapport and support patient-identified goals of care.
• Provides longitudinal care management for patients with high-risk, high-utilization, or complex needs while collaborating with RN Care Managers, Health Coaches, Community Health Workers, pharmacy teams, behavioral health, and primary care providers to ensure coordinated interventions and shared accountability.
• Connects patients to appropriate internal and external resources, including financial assistance, home- and community-based services, benefits programs, transportation, food supports, caregiver services, housing solutions, and behavioral health services.
• Ensures referrals are tracked, followed up, and closed with documented outcomes.
• Assists in the orientation of new staff or continuing education of existing staff as requested.
• Delivers supportive intervention and problem-solving related to adjustment to illness, caregiver strain, grief, behavior change, and medical decision-making, while assisting patients and families in understanding and engaging in treatment plans, care expectations, and available support systems.
• Assists with complex issues such as guardianship, advance directives, disability applications, and long-term care planning, and collaborates with hospital programs and community agencies involved in the patient's care.
• Participates in care transition planning to ensure safe and coordinated movement between hospital, post-acute, and home settings.
• Maintains accurate, timely, and clinically appropriate documentation in the electronic health record and consistently meets assigned productivity, outreach, engagement, and outcome expectations.
• Participates in interdisciplinary case reviews, huddles, and care team meetings, and actively seeks consultation or direction from management personnel as appropriate.
• Participates in staff development and in-service programs, as requested, and promotes a positive corporate image.

Common Expectations:

• Adheres to all safety regulations, organizational policies, and quality standards; identifies opportunities to reduce errors, supports infection control practices, and participates in safety education and root-cause analysis as required.
• Participates in ongoing education, in-service training, and professional growth activities; provides outstanding service to patients and colleagues; and contributes to teamwork, innovation, and fiscal responsibility.
• Completes timely and appropriate documentation in the electronic medical record, ensures care plans and interventions are captured appropriately, and attends required meetings and departmental activities.