Transitions of Care Coordinator (Social Worker)

Job Title

Transitions of Care Coordinator (Social Worker)

Posting Date

August 2, 2023


  • Bachelor’s or Master’s degree in Social Work preferred.
  • One to two years’ experience preferred.
  • Must be licensed as a Social Worker in the State of Wisconsin.

Work Hours

We are seeking a full-time (40 hours/week) Transitions of Care Coordinator to work Monday-Friday.

Job Summary

The Transitions of Care Coordinator will coordinate activities that promote quality outcomes, patient throughput and discharge planning while supporting a balance of optimal care and appropriate resource utilization. The Transitions of Care Coordinator will identify potential barriers to patient throughput and quality outcomes minimizing delays in discharge plans.

Essential Job Functions and Responsibilities

This list of duties and responsibilities is not all inclusive and may be expanded to include other duties and responsibilities as management may deem necessary from time to time.

  1. Coordinates Social Service functions in the Hospital, including patient/family related psychosocial issues.
  2. Coordinates and participates in patient care plan conferences.
  3. Coordinates discharge planning and services for patients within the hospital and ER upon discharge as needed.
  4. Provides direct care to patients in the hospital as necessary.
  5. Updates care plans and discharge plans.
  6. Provides UR services and Case Management.
  7. Serves as the Client Rights Specialist.
  8. Serves as the Ethics Committee Coordinator.
  9. Serves as liaison between all medical staff, families, and patients.
  10. Rounds daily on inpatients.
  11. Serves as the patient/family complaints coordinator, addressing patient complaints and working with departments to resolve issues.
  12. Attends staff meetings and in-services.
  13. Educates new employees on regulatory requirements including patient rights and abuse.
  14. Responsible for managing Social Services policies.
  15. Adheres to Southwest Health’s value-based behavior standards.
  16. Understands and adheres to Southwest Health compliance and HIPAA standards as they appear in the Corporate Compliance Policy, Code of Conduct and Conflict of Interest Policy.
  17. Performs other duties and responsibilities as requested or required.

We believe that together we can change lives, and we anticipate your life will change in the process. If you aspire to help others find hope and live better, we invite you to submit your application below. Click Here to learn what others say about SH.


SH is truly an outstanding place to work. A full benefit package is available for employees working 20 hours/week or greater which includes: Health, Dental, Vision and Life insurance. Also available are long and short term disability, cell phone discount, flexible spending plan, paid time off, retirement plan with an employer contribution, fitness membership discount as well as use of exercise equipment at the facility.


Contact Info

Southwest Health
Attn: Human Resources
1400 East Side Rd
Platteville, WI 53818
Phone: (608) 342-4796
Fax: (608) 342-5015

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