Medical Social Worker/Care Coordinator

The Hospice Care Coordinator Social Worker plays a key role in initiating compassionate and comprehensive hospice services for patients and families. This position performs in-person or virtual consults, providing education and support around end-of-life care, assessing psychosocial needs, and coordinating services. As a social worker, the Care Coordinator brings expertise in communication, counseling, and care navigation to support informed decision-making during a critical time. The Care Coordinator is responsible for coordinating the referral-to-admission process for hospice patients. Respond to hospice consult requests from hospitals, nursing facilities, physicians, or internal referral sources.Conduct timely in-person assessments with patients and families to introduce hospice services and guide eligibility discussions.Provide education on hospice philosophy, services, coverage, and the interdisciplinary team approach.Complete psychosocial assessments and support families through emotional, financial, or caregiver-related concerns.Serve as a liaison between referral sources and the hospice team to facilitate seamless transitions of care.Collaborate with admissions nurses and the hospice interdisciplinary team to ensure timely and appropriate admissions.Document assessments, communications, and interventions according to agency policy and regulatory requirements.Build and maintain positive relationships with referral sources, including hospitals, skilled nursing facilities, and clinics.Participate in team meetings and provide feedback to improve the consult and intake process.Remain up to date on hospice regulations, best practices, and community resources. Social Work Consult: Conduct thorough psychosocial assessments during initial hospice consults, identifying patient and family needs, strengths, and barriers.Provide emotional support, active listening, and crisis intervention to patients and families during periods of uncertainty or distress.Assist patients and families in understanding their prognosis and care options while respecting cultural, spiritual, and personal values.Address concerns related to caregiver burden, family dynamics, advance directives, financial hardship, and grief.Connect families with appropriate community resources such as financial aid, transportation, spiritual support, and respite services.Promote autonomy and dignity for patients by supporting informed decision-making and self-determination.Communicate findings to the hospice interdisciplinary team to ensure continuity and coordination of care from the very first encounter. The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.