What are the responsibilities and job description for the Medical Respite Complex Care Coordinator (LSW) position at Public Health Management Corporation?
PHMC is proud to be a leader in public health. Our Mission is to be the premier regional provider of integrated, community-based healthcare by combining evidence-based clinical practices, outstanding patient service, innovative care partnerships, and team-driven excellence, within a healthy fiscal environment.
JOB DESCRIPTION:
The Medical Respite Complex Care Coordinator provides direct social services and care coordination to patients across PHMC Health Medical Respite locations. The Medical Respite Complex Care Coordinator will play a central role in leading patient intake, connecting patients to public benefits, participating in care planning, coordinating patient discharges, and supporting safe transitions of care.
The Medical Respite Complex Care Coordinator works intensively with diverse and underserved patient populations staying at the PHMC Health medical respite and collaborates with PHMC Health Center staff to improve patient health outcomes. The Complex Care Coordinator also serves as a primary point of contact for external referral sources, medical offices, and family members, ensuring clear communication and continuity between hospital systems, the PHMC Respite Programs, and community placements. The Medical Respite Complex Care Coordinator actively engages as a member of the PHMC Health social service team and participates in all PHMC Health social service training sessions.
The Medical Respite Complex Care Coordinator must possess, at minimum, a License in Social Work (LSW) and will receive clinical supervision from an LCSW from within the Health Network, when needed.
Responsibilities:
JOB DESCRIPTION:
The Medical Respite Complex Care Coordinator provides direct social services and care coordination to patients across PHMC Health Medical Respite locations. The Medical Respite Complex Care Coordinator will play a central role in leading patient intake, connecting patients to public benefits, participating in care planning, coordinating patient discharges, and supporting safe transitions of care.
The Medical Respite Complex Care Coordinator works intensively with diverse and underserved patient populations staying at the PHMC Health medical respite and collaborates with PHMC Health Center staff to improve patient health outcomes. The Complex Care Coordinator also serves as a primary point of contact for external referral sources, medical offices, and family members, ensuring clear communication and continuity between hospital systems, the PHMC Respite Programs, and community placements. The Medical Respite Complex Care Coordinator actively engages as a member of the PHMC Health social service team and participates in all PHMC Health social service training sessions.
The Medical Respite Complex Care Coordinator must possess, at minimum, a License in Social Work (LSW) and will receive clinical supervision from an LCSW from within the Health Network, when needed.
Responsibilities:
- Direct Patient Care & Case Management
- Conduct multidisciplinary intakes and assessments within 48 business hours of admission to identify barriers to recovery and discharge readiness.
- Develop individualized care plans with clear, time-limited goals aligned with medical, behavioral, and social priorities.
- Provide brief counseling and support focused on motivation, problem-solving, and resource navigation.
- Coordinate daily with nursing and medical respite staff regarding changes in patient needs, barriers, or discharge timelines.
- Participate in telehealth appointments as needed to support communication and care continuity.
- Provide same-day assistance with transportation coordination for discharges, follow-ups, or appointments.
- Field and respond to calls from family members, care managers, or medical providers related to patient status and social needs.
- Facilitate safe and appropriate transitions to Skilled Nursing Facilities (SNFs), shelters, or community-based housing.
- Serve as a liaison between hospitals, respite programs, and external agencies to ensure continuity of care.
- Ensure that all necessary medical and social documentation is complete and transmitted before discharge.
- Track discharge outcomes and report barriers to the Medical Respite leadership.
- Complete social determinants of Health (SDOH) screenings and link patients to relevant resources (housing, food, transportation, utilities, income supports, etc.).
- Support with medical insurance enrollment, renewals, or reinstatement to prevent coverage lapses.
- Make or receive referrals to the PHMC Health Medical Respite program based on social needs and readiness criteria.
- Participate in interdisciplinary team meetings to coordinate care across medical, behavioral health, and social service disciplines.
- Collaborate with external providers to maintain alignment around patient goals.
- Document all interventions, referrals, and communications in the electronic health record (EHR) in a timely and compliant manner.
- Contribute to program data collection for Patient-Centered Medical Home (PCMH), Social Determinants of Health (SDOH), and transition of care reporting metrics.
- Maintain accurate tracking of caseload and discharge dispositions across multiple sites.
- Deep understanding of community resources, housing systems, and public benefit programs.
- Strong skills in care coordination, discharge planning, and multidisciplinary teamwork.
- Excellent verbal and written communication, including with hospitals and external agencies.
- Ability to adapt to a dynamic, transitional environment with varying patient lengths of stay.
- Working knowledge of motivational interviewing and trauma-informed care principles.
- Proficient in electronic documentation
- Excellent time management skills with demonstrated ability to work across multiple sites.
- Experience working as a member of an interdisciplinary team, preferred.
- Two years of social work experience in medical, respite, homeless, or behavioral health settings.
- Experience in hospital discharge planning, homeless services, or transitional care strongly preferred.
- A Master's Degree in Social Work is required
- Licensed Social Worker (LSW) in Pennsylvania required.
