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Social Worker - Sub Acute and Therapy

Job ID: 150774
Category: Social Work
Work Type: FT
Location: Philadelphia, PA, United States
Date Posted: Oct 12, 2022

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Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?


The Social Worker serves as a liaison between Long Term Care (LTC) facility (SNF, PCH, etc.) leadership and Penn Medicine stakeholders to ensure all parties invested in the care of Residents or Patients meet mutual expectations of accountability for quality and efficiency of care. The expectations for accountability include:

  • Ensure timely and seamless bi-directional transitions of care and follow up consistently
  • Implement programs to support the highest level of patient/resident care
  • Pro-actively identify systemic gaps in transitions of care or programing with potential solutions
  • Maintain highly collaborative relationships with all stakeholders of care
Functions as a key member of the interdisciplinary Sub-Acute Team and the subject matter expert as well as primary resource for social services expertise. Shares accountability for a group of LTC Facilities with emphasis on partnership with Personal Care Homes(PCH) and Assisted Living Facilities (ALF). Provides consultative services for other Sub-Acute levels of care including Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs) and Long Term Acute Care Hospitals (LTACHs). Finally, but foundationally, the Social Worker is accountable to facilitate a highly effective work culture for the Program and its reputation within Penn Medicine a well as among external stakeholders.


  • Timely and seamless transitions of care and follow-up:
    • Establishes and maintains relationships with LTC Facility that are characterized by patient centeredness, collaboration and respect.
    • Consistent check-in regarding resident census to assist in tracking resident hospitalization and discharge; monitors referrals of Penn Medicine patients to each LTC facility.
    • Connects LTC Facility with Penn Medicine inpatient and outpatient providers of care, including home health, care management, behavioral health providers etc. to foster continuity of care.
    • Monitors the effectiveness of LTC Facility-Penn Medicine acute care transfers in terms of information-sharing and outcomes; updates, informs and engages Penn Medicine inpatient care management staff regarding initiatives to improve care coordination across settings.
    • Monitors the post-facility discharge experience of patients to look for gaps in care and need for improvement of care processes.
    • Creates and maintains ongoing relationships with facility/Penn Medicine leadership and clinicians, IT, compliance, care management, private practices, home health agencies, dialysis centers, Department of Aging, Adult Protective Services, Department of Social Services.
    • Expands scope of the Post-Acute Social Work role to involve evaluation of and collaboration with other types of post-acute providers (Drug and alcohol rehabs etc.).
    • Assists and supports in establishing a Penn Medicine PCH/ALF network in relevant counties.
  • Maintain strong partnerships with LTC Facility Leadership to support the highest level of patient/resident care
    • Performs LTC facility visits independently or as a member of the team to assess needs and identify opportunities for partnership and support; responds to facility concerns and facility staff needs that Penn Medicine can address.
    • Contributes to the development and facilitation of training, education and peer networking activities aimed at LTC administration, staff, and residents within areas of expertise.
    • Outbreak Response: (when appropriate)
      • Responds to Facility needs within 24-48hrs. of an outbreak as part of a Rapid Response Team (MD, RN, SW).
      • Maintains knowledge/relationships with community health care providers and resources to support Resident transitions as appropriate during an outbreak.
      • Identify and provide guidance to facilities regarding resident/staff behavioral health needs/resources.
      • Continuously expand knowledge and understanding of community resources, services and programs that are appropriate for PCHs.
    • General and administrative accountabilities:
      • Maintains tracking and appropriate documentation for ongoing program assessment and management
      • Assists with the development and implementation of program standards, policies and procedures; consistent with program goals.
      • Highly competent preparing and disseminating meaningful information from program results in a concise manner.
      • Participates in continuous improvement activities.
      • Enhances own professional development and maintains formal and informal continuing education for self-development


  • Licensed Social Worker (LSW) in Pennsylvania - preferred

Education or Equivalent Experience:

  • Master's Degree in Social Work and 2+ years clinical experience - required
  • 1+ years experience Post-acute care (SNF, IRF, Home Health) - preferred

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

   Current UPHS employees must apply HERE
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