Are you an experienced Licensed Clinical Social Worker (LCSW) passionate about improving patient journeys beyond the hospital walls? Do you excel at navigating complex hospital systems and coordinating seamless transitions of care?

myLaurel is seeking a dedicated and experienced Senior Clinical Liaison - Care Transitions LCSW based in Brooklyn, NY to help launch and expand our innovative home-based acute care services within a leading partner hospital system.

You will leverage your deep understanding of hospital operations, patient flow, and discharge processes to identify appropriate patients and facilitate their smooth transition to myLaurel's specialized home care programs. Your expertise in care coordination, case management principles, and relationship building will be crucial for success. You will act as a key liaison, ensuring continuity of care, preventing readmissions, and advocating for patients moving from the hospital back to their homes.

About Us: myLaurel is a leader in home-based acute care tailored to the needs of frail, elderly, and complex patients. Our innovative Recovery at Home, Rapid Advanced Care, and Acute Care at Home models provide unmatched utilization reduction and readmission prevention for high-risk populations. Utilizing an interdisciplinary team of telehealth physicians, in-home paramedics, and RN care managers, myLaurel ensures patients avoid the conventional acute care journey from ER to admission to post-acute care. The innovative care model creates dramatic cost savings, helps patients avoid hospital-acquired conditions, and radically improves the patient and caregiver experience.

myLaurel Health has three clinical service programs:

• Rapid Advanced Care: On-demand in-home acute care
• Acute Care at Home: Hospital patients are discharged home, and advanced care is continued in the home while simultaneously providing transition care, reducing time in the hospital and significantly reducing readmissions
• Recovery at Home: Post-hospital discharge program

Key Responsibilities:

• Patient Identification & Transition Assessment: Actively screen and assess hospitalized patients to determine eligibility and suitability for myLaurel's home-based care programs, focusing on transition needs and clinical stability.
• Care Coordination & Transition Management: Orchestrate seamless handoffs from the hospital to myLaurel's home care teams. Collaborate closely with hospital physicians, case managers, discharge planners, nurses, social workers, and other healthcare professionals to ensure all aspects of the transition are managed effectively.
• Relationship Building: Cultivate and maintain strong, collaborative partnerships with hospital leadership, medical staff, case management/discharge planning teams, and other key stakeholders to facilitate program integration and support.
• Referral Pathway Development: Proactively build and strengthen referral pathways within the hospital system to increase awareness and enrollment in myLaurel programs.
• Patient & Caregiver Engagement: Clearly explain myLaurel's services to eligible patients and their caregivers, ensuring understanding of the home care model, managing expectations, reinforcing discharge instructions relevant to the transition, and securing consent.
• Strategic Collaboration: Partner closely with myLaurel's Client Success team to execute a growth strategy for the service line, ensuring alignment with both myLaurel's and the hospital's objectives.
• Team Collaboration: Work effectively within the broader myLaurel clinical and operational teams.

Typical Day in the Life: Your day will be dynamic and largely based within the hospital setting. You'll likely attend hospital rounds or huddles (e.g., multidisciplinary rounds, case management meetings), conduct targeted chart reviews and analyze patient census data, track referrals, liaise with hospital staff (especially case managers and physicians), and engage with patients/caregivers to discuss program options. You are the bridge ensuring smooth transitions.

Requirements:

• Current and unrestricted LCSW license in New York.
• Minimum of 5 years of Clinical Social Work and/or Care Transitions experience, demonstrating a strong understanding of acute care settings, hospital workflows, and patient flow dynamics.
• Significant experience in roles focused on care coordination, case management, discharge planning, utilization review, or patient navigation within a hospital, health system, or related setting is strongly preferred.
• Proven ability to navigate complex healthcare systems and build effective relationships with diverse clinical and administrative staff.
• Excellent communication, interpersonal, and patient engagement skills.
• Strong analytical and problem-solving abilities, particularly in assessing patient needs for transition planning.
• Self-driven with excellent organizational and time management skills; ability to work independently and manage priorities.
• A Master of Social Work (MSW) is required.
• Comfortable working in a hospital environment and collaborating with hospital teams.

Please Note: While clinical knowledge is essential, this role's primary functions are centered on assessment for program appropriateness, care coordination, transition management, and relationship building.

Key Competencies:

• Expertise in care coordination, transition management, and discharge planning principles.
• Deep understanding of hospital operations, interdisciplinary team communication, and navigating healthcare system complexities.
• Excellent collaboration and interpersonal communication skills.
• Strong patient advocacy skills.

Special Considerations: This role requires a combination of computer work (chart review, documentation, communication) and active presence within the hospital (walking units, attending meetings, patient interaction). Comfort with both desk work and being mobile throughout the hospital is necessary.

Compensation & Benefits:

• Salary Range: $85,000-$93,000 annually; includes productivity bonus based on performance metrics.
• Comprehensive benefits package including health insurance, retirement plans, and paid time off.

Apply today to join our innovative team and play a critical role in transforming how patient care is delivered!