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Social Worker / Discharge Planning Coordinator - Care Navigation - Acute - Full Time - Days

Toledo, Ohio
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ProMedica Toledo Hospital is one of the largest acute-care facilities in the region. Our 794-bed hospital is staffed by more than 4,800 professional healthcare employees who serve a 27-county area throughout northwest Ohio and southeast Michigan. We also have the area’s largest board-certified medical staff, which is made up of more than 1,000 primary care and specialty physicians. Excellent customer service skills and the ability to work in a fast paced environment are a must. In addition, for 15 consecutive years, residents of Greater Toledo have named us the Consumer Choice Award winner in our market. In fact, we’re the only hospital in northwest Ohio to receive this honor.

Position Summary:

Responsible for coordinating placement, community agency referral, and social coping aspects for patients in the assigned areas, inclusive of all age groups served. Serve as a referral source and resource to other staff in an effort to promote the delivery of high quality, fiscally responsible continuing care services. Individual provides psychosocial support and guidance to meet the needs of the patient.

Primary Duties:

  • Proactively follows up with inpatient referrals and consults.
  • Conducts interviews with patients and family members to develop therapeutic relationships and obtain psychosocial and financial information necessary for the facilitation of appropriate discharge planning.
  • Performs psychosocial assessment on all referrals and mental health or substance abuse assessment as needed and documents within 24 hours of referral.
  • Completes the following psychosocial transition planning services: New facility placements, New dialysis patients, Hospice, Rapes, Teen pregnancy, Homeless, Domestic violence/domestic dispute, Abuse, Counseling, Adult protective/Child protective services, Guardianship, Crisis intervention, other tasks as appropriate
  • Provides information to patients and families about community resources - including skilled nursing and acute rehabilitation facilities, financial programs, counseling agencies, and other providers of concrete and supportive services - and educate them, as needed, about steps needed in selecting and accessing community resources, documenting patient choice of the final selection.
  • Counsels patients and families, as appropriate, regarding issues related to adjustment to illness, difficulties in accessing community resources, financial difficulties, future long-term care planning, protection issues, advance directives, and other psychosocial problems.
  • Effectively communicates with hospital staff, patients, and families, and outside resources information needed to facilitate timely and appropriate discharges and provide other needed services to families.
  • Refers patients and family members to in-house (financial counselor, chaplain, etc.) and community resources for help with financial programs and other tangible resources, rehabilitation and nursing services, counseling and support services, and other psychosocial needs.
  • Provides assistance to members of the interdisciplinary team regarding community resources and agencies, financial programs, regulatory standards and other psychosocial needs.
  • Documents required and other pertinent information on the patient’s medical chart, including psychosocial information and final transition plan, to describe progress on cases, clearly indicating that patient choice was encouraged regarding community resources and what the final choice is.
  • Works collaboratively with patients, families, and health care team members in the coordination and monitoring of activities of all parties to ensure transition plans are implemented in a timely and fiscally responsible manner.
  • Serves as a patient advocate during the course of the patient’s hospitalization with a goal of promoting a sense of the continuum of care and a climate of concern for individual patient/family welfare.
  • Establishes and maintains positive working relationships with patients, family members, and members of the health care staff, incorporating positive customer service standards into daily work.
  • Ensures appropriate transportation is arranged for patient discharge.
  • Escalates concerns to leadership, as appropriate.
  • Works collaboratively with system and non-system referral sources to proactively identify and screen prospective patients to be admitted into the program
  • Completes other duties as assigned.


  • Must be a licensed social worker
  • Previous case management or discharge planning experience preferred.
  • Must have knowledge of federal regulations and community resources.
  • Must be able to function effectively in an office setting, while communicating virtually with clients using various tele and video technology platforms.
  • Written and verbal skills essential.
  • Must be able to establish priorities and communicate and respond to inquiries.
  • Must be able to stand for long periods of time.
  • Must be able to work rapidly for long periods of time.



ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio.  For more information, please visit

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact

Equal Opportunity Employer/Drug-Free Workplace

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