Vanessa Guedes
North Arlington
Summary
Licensed Medical Social Worker with 6+ years of progressive experience in complex discharge planning, hospital-based case management, and system-level escalation support across large academic medical centers. Brings advanced expertise in resolving high barrier, long length of stay cases involving, medical complexity, immigration issues, payer denials, and regulatory barriers. Recognized for leadership, cross system coordination, and patient centered problem solving.
Overview
7
7
years of professional experience
Work History
Senior Social Worker
New York Presbyterian Medical Center
03.2025 - Current
- Serve as a resource to frontline social work and case management teams on high- complexity discharge cases with prolonged hospitalizations and multifactorial barriers.
- Provide enterprise level support in identifying and resolving medical, psychosocial, legal, immigration, and regulatory obstacles.
- Collaborate with hospital leadership, legal counsel, post-acute providers, and external agencies to facilitate safe, compliant patient transitions.
- Lead escalation pathways involving city, state, and federal entities to resolve eligibility, placement, coverage and service access barriers.
- Support standardization of Epic documentation and escalation workflows to improve regulatory compliance, interdisciplinary communication, and system efficiency.
Discharge Planner
Hospital for Special Surgery, Main Campus
03.2025 - Current
- Coordinated discharge plans to ensure timely patient transitions from hospital to home care.
- Collaborated with multidisciplinary teams to assess patient needs and develop comprehensive care strategies.
- Facilitated communication between patients, families, and healthcare providers regarding post-discharge instructions.
- Utilized electronic health records to track patient progress and update discharge documentation accurately.
Social Work Case Manager
Hackensack University Medical Center
03.2019 - 02.2025
- Conducted comprehensive psychosocial assessments across inpatient medical and surgical units to evaluate clinical and social drivers impacting discharge.
- Led complex discharge planning to SNF, Acute Rehab, LTACH, a nd home-based care/
- Served as subject matter resource for long length of stay and high risk cases.
- Coordinated international medical repatriation.
- Partnered with physicians, nursing leadership, rehab teams to align discharge plans with clinical and operational requirements.
Dialysis Social Worker
Fresenius Kidney Care Dialysis
07.2019 - 02.2020
- Conducted comprehensive psychosocial assessments for patients to identify needs and develop tailored care plans.
- Facilitated support groups and educational workshops to enhance patient coping strategies and community engagement.
- Coordinated transplant education, referrals, and community-based resources.
- Facilitated family meetings to discuss patient care plans.
Education
Master of Social Worker - Social Work
Rutgers University
New Brunswick, New Jersey, NJ05-2019
Bachelor of Arts - Psychology
Montclair State University
Montclair, NJ05-2017
Associate of Arts - Psychology
Hudson County Community College
Jersey City, NJ05-2015
Skills
- Proficient in Spanish
- Proficient in Portuguese
- Complex discharge escalation strategies
- Experienced in resolving complex cases
- Insurance Appeals
Accomplishments
- Social Worker of the Year- NewYork-Presbyterian Hospital 2025
- People First Award- Hackensack University Medical Center 2023
- Social Worker of the Year- Hackensack University Medical Center 2021
Timeline
Senior Social Worker
New York Presbyterian Medical Center
03.2025 - Current
Discharge Planner
Hospital for Special Surgery, Main Campus
03.2025 - Current
Dialysis Social Worker
Fresenius Kidney Care Dialysis
07.2019 - 02.2020
Social Work Case Manager
Hackensack University Medical Center
03.2019 - 02.2025
Master of Social Worker - Social Work
Rutgers University
Bachelor of Arts - Psychology
Montclair State University
Associate of Arts - Psychology
Hudson County Community College