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Job Summary Responsible for, and will participate in, the assessment, planning, implementing, coordinating, communicating and finalizing the discharge of the patient/resident form the hospital setting or rehab and nursing center. Works with other members of the health care team both inpatient and outpatient, to advocate for and ensure appropriate aftercare and follow up. Essential Functions
Competently gathers information using assessment skills to identify physical, psychosocial, financial and environmental health care needs of the patient/resident. Assess and identify appropriate resource utilization, level of care and treatment options to develop a plan of care that will impact quality outcomes in a cost effective manner. Collaborates with the patient/resident, family and health care team to promote quality care, prevent delay in discharge and complications to improve outcomes. Work with the patient and physician to develop a plan of care that meets their needs and will avoid duplication and or fragmentation of services. Ensure appropriate use of ancillary services providing guidance and direction and implementing modification to the plan of care as needed. Efficiently documents assessments, clinical findings, completed tasks, plan for treatment and progress toward goals for discharge. Keep accurate record of patient/family contact and team consultation. Works to actively facilitate an appropriate level of care for discharge and educate the patient on the progress of the discharge plan and the safety and benefits of the plan. Monitor, evaluate, and coordinate referrals from multiple sources, while measuring patient care outcomes, interpreting reports and addressing data from sources to better serve and impact the patient and their adjustment to illness and treatment. Actively promotes frequent communication between all team members, providers, patients and family members to ensure a smooth transition from one level of care to another. Share and educate on community resources, support systems and available benefits. Maintain communication with providers delivering care to ensure consistency in communication to patient/resident and family. Demonstrate self directed, self motivated, responsible behavior recognizing when there is a need for adjustment and flexibility in professional function. Respect confidentiality of all parties involved in the patient/resident care process and utilize the professional skills of other team members and disciplines for improvement in the discharge plan. Qualifications
Required
Bachelor's Degree Social Work: Exceptions for persons without a
social work degree can be made for those who have a human
services degree and carry a current social work
license OR Bachelor's Degree Social Work or a human services field including, but not limited to, Sociology, Gerontology, Special Education, Rehabilitation Counseling, and Psychology (Rehab and Nursing Centers only) 1 year of relevant experience Supervised social work experience in health care setting working directly with individuals. (Rehab and Nursing Centers only) LIC-Bachelor Social Worker (BSW) - STATE_MI State of Michigan Excludes Rehab and Nursing Centers Upon Hire required Preferred
1 year of relevant experience skilled nursing home process and procedure 1 year of relevant experience mental health, substance abuse assessment and treatment 1 year of relevant experience community resources and discharge planning 3 years of relevant experience Hospital or Nursing Home Social work
How Corewell Health cares for you
Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here. On-demand pay program powered by Payactiv Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more! Optional identity theft protection, home and auto insurance, pet insurance Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status
Primary Location SITE - Pine Ridge Nursing & Rehab Center - 4368 S Cleveland Ave - Stevensville
Department Name Social Services - Pine Ridge
Employment Type Full time
Shift Day (United States of America)
Weekly Scheduled Hours 40
Hours of Work 8:00 a.m. to 4:30 p.m.
Days Worked Monday to Friday
Weekend Frequency Variable weekends
CURRENT COREWELL HEALTH TEAM MEMBERS - Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only. Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling 616.486.7447.
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Corewell Health
Jun 29, 2025