Location: Baltimore, Maryland / Remote
Position Type: Contract 1099 Parttime M-F
Reports To: Clinical Program Leadership
Position Summary
We are seeking a compassionate, resourceful, and highly organized Social Worker to support patients participating in a Hospital Readmission Reduction Program following discharge from a Baltimore-area hospital. The Social Worker will collaborate with nurses, advanced practice providers, enrollment staff, hospital partners, patients, caregivers, and community organizations to identify and address social and environmental barriers that may increase a patient's risk of readmission. Patients are followed for approximately 30 days after hospital discharge.
This is a remote care coordination and resource-navigation role. The position focuses on connecting patients with appropriate community and social resources, resolving barriers to successful recovery at home, and documenting the outcome of interventions.
Key Responsibilities
- Receive and respond to social work and SDOH escalations identified during the patient's 30-day post-discharge period.
- Conduct focused assessments of social, environmental, financial, and access-related barriers affecting the patient's ability to follow the discharge plan.
- Assist patients and caregivers with identifying and accessing appropriate community resources.
Address barriers involving:
- Transportation to medical appointments
- Food insecurity and meal assistance
- Housing instability or unsafe living conditions
- Utility insecurity
- Medication affordability and financial assistance resources
- Home health and community-based services
- Caregiver support
- Durable medical equipment and other home resource needs
- Insurance or benefits navigation
- Access to primary care and community services
- Other social determinants of health that may contribute to readmission risk
- Coordinate transportation resources for post-discharge medical appointments when appropriate.
- Research and maintain familiarity with Baltimore City, Baltimore County, Maryland, and federal community assistance programs.
- Contact community organizations and service agencies on behalf of patients when appropriate and assist with navigating eligibility and enrollment processes.
- Provide patients and caregivers with clear instructions and contact information for recommended resources.
- Follow up on open social work escalations to determine whether the identified need was successfully resolved.
- Escalate unresolved or urgent concerns to the appropriate clinical team member or hospital/community partner.
- Collaborate closely with the RN and other clinical team members managing the patient's 30-day post-discharge outreach.
- Communicate intervention updates and unresolved needs through the program's designated communication channels.
- Identify recurring social barriers and community resource gaps and communicate trends to program leadership.
- Maintain patient confidentiality and comply with HIPAA, organizational policies, and applicable state and federal requirements.
Patient Population
The Social Worker will support designated patient populations enrolled in the Hospital Readmission Reduction Program. Initial populations may include patients discharged following hospitalization for or with conditions such as:
- Congestive Heart Failure (CHF) + Chronic Kidney Disease (CKD)
- Vascular surgery procedures
Additional patient populations may be incorporated as the program expands. Patients may have complex medical and social needs and may experience multiple barriers that affect their ability to successfully transition home after hospitalization.
Role Within the 30-Day Workflow
The Social Worker serves as a specialized resource within the interdisciplinary post-discharge team. The Social Worker is not expected to replace the patient's hospital social worker, primary care provider, home health team, or other established community services. Instead, the role provides additional post-discharge support to help close gaps that emerge after the patient returns home.
Required Qualifications
- Bachelor's degree in Social Work from an appropriately accredited program.
- Appropriate Maryland social work licensure for the duties assigned to the position.
- Experience in social work, case management, care coordination, healthcare, community health, or a related setting.
- Knowledge of social determinants of health and their impact on health outcomes and hospital utilization.
- Strong knowledge of, or ability to quickly develop expertise in, Baltimore-area and Maryland community resources.
- Strong telephone communication and patient-engagement skills.
- Ability to communicate effectively with older adults, caregivers, healthcare professionals, and community organizations.
- Strong documentation and organizational skills.
- Ability to independently prioritize multiple patient needs and time-sensitive escalations in a remote environment.
- Comfortable working with electronic health information, web-based care management platforms, and virtual communication tools.
- Ability to maintain confidentiality and comply with HIPAA requirements.
Preferred Qualifications
- Active Maryland LMSW, LCSW, or LCSW-C license, as appropriate for the finalized scope of the position.
- Previous hospital, transitional care, population health, case management, home health, or post-acute care experience.
- Experience working with Medicare populations, older adults, or medically complex patients.
- Experience supporting patients with SDOH-related barriers.
- Established familiarity with Baltimore City and Baltimore County community resources.
- Experience working as part of an interdisciplinary clinical team.
- Experience with hospital readmission reduction, transitions of care, or value-based care programs.
Measures of Success
Performance may be evaluated using measures such as:
- Timeliness of response to social work escalations
- Percentage of escalations successfully resolved or connected to an appropriate resource
- Transportation requests successfully coordinated
- Patient connection to community resources
- Documentation completeness and timeliness
- Follow-up on unresolved patient needs
- Identification of recurring SDOH barriers
- Collaboration and communication with the clinical care team
- Contribution to the program's overall goal of supporting successful transitions home and reducing avoidable hospital readmissions
Work Environment
This is a hybrid remote position supporting patients in the Baltimore, Maryland area. Patient engagement will primarily occur by telephone and other approved remote communication methods. The Social Worker will work closely with a remote interdisciplinary clinical team and designated hospital partners. The position requires reliable internet access, a private workspace suitable for handling protected health information, and the ability to work within established HIPAA and information-security requirements.
Mission of the Role
The goal of this position is to help ensure that patients do not return to the hospital because a preventable social or resource barrier went unresolved after discharge. By identifying needs, connecting patients with appropriate resources, and closing the loop on social work escalations, the Social Worker will serve as an important extension of the Hospital Readmission Reduction Program throughout the patient's 30-day transition from hospital to home.
Pay: From $30.00 per hour
Expected hours: 10.0 – 15.0 per week
Application Question(s):
- 1. Do you currently hold an active Maryland social work license?
- Yes — LBSW
- Yes — LMSW
- Yes — LCSW or LCSW-C
- No
- 2. How much experience do you have with Baltimore-area healthcare or community resource programs?
- Less than 1 year
- 1–2 years
- 3–5 years
- More than 5 years
- 3. Can you perform occasional in-person patient engagement activities in the Baltimore area?
- Yes
- No
- 4. Are you comfortable with variable part-time hours without a guaranteed weekly minimum?
- Yes
- No
Work Location: Hybrid remote in Baltimore, MD 21201
