Medical Social Worker - Flat Shoals Clinic

Location: 4025 Flat Shoals Parkway, Decatur, GA 30034
Schedule: Monday-Friday, Day Shift (No nights or weekends)

Grady Health System is expanding care access in South DeKalb County with the opening of our newest and largest neighborhood health center: Flat Shoals Clinic. This state-of-the-art outpatient center includes 13 exam rooms, imaging capabilities, and on-site pharmacy services-designed to bring quality care closer to where people live and work.

We're seeking a compassionate and experienced Medical Social Work Care Manager to support our care coordination team and help patients achieve better health outcomes through timely, proactive case management and smooth transitions of care.

The Medical Social Work Care Manager works collaboratively with the Clinical Care Coordinator (C3), care management team, and interdisciplinary healthcare providers to support patients across the continuum of care. This role uses clinical social work skills to develop discharge plans, coordinate services, and reduce unnecessary delays in treatment or transitions.

Responsibilities include patient advocacy, discharge planning, outpatient case management, and helping patients access resources that support safe, appropriate post-care environments.

• Conduct psychosocial assessments of patients and families to identify needs related to mental health, social support, financial challenges, housing, transportation, food insecurity, and safety.
• Provide crisis intervention, supportive counseling, and referral to behavioral health and community resources as needed.
• Collaborate with physicians, nurses, case managers, and other clinic staff to support treatment planning and continuity of care.
• Develop care plans to address social determinants of health and monitor progress toward goals.
• Educate patients and families about available community resources, entitlement programs, and support services.
• Facilitate referrals to substance use treatment, domestic violence services, and other specialized care programs.
• Advocate for patients to ensure equitable access to healthcare and community-based supports.
• Assist with discharge planning, follow-up coordination, and reduction of avoidable hospital admissions.
• Document all patient interactions, assessments, interventions, and outcomes in the electronic medical record in accordance with organizational and regulatory standards.
• Participate in clinic team meetings, case conferences, and quality improvement initiatives.
• Provide health education workshops and support groups as appropriate.
• Maintain professional knowledge through continuing education and adherence to ethical standards of social work practice.

• Master's Degree in Social Work (MSW) - Required

• Licensed Medical Social Worker (LMSW) - Preferred

• Case Manager Certification or Accredited Case Manager (ACM) - Preferred

• Prior experience providing medical social work or case management services - Preferred

• Experience in a hospital or outpatient care setting - Preferred

• Be part of a high-impact clinic launch serving a vibrant, underserved community

• Collaborate with a mission-driven team committed to health equity and access

• Enjoy consistent weekday hours-no weekends or holidays

• Help shape the future of community-based care at Grady's newest facility

Grady Health System is an Equal Opportunity Employer.