Position Summary
The Social Worker is responsible for supporting the psychosocial, emotional, and discharge planning needs of residents in a skilled nursing facility. This position serves as an advocate for residents and families while coordinating services that promote resident rights, quality of life, dignity, and emotional well-being. The Social Worker collaborates with the interdisciplinary team to ensure residents receive appropriate support, resources, and care planning throughout their stay.
Essential Duties and Responsibilities
Resident Care & Support
- Complete psychosocial assessments for residents upon admission, quarterly, annually, and with significant changes.
- Develop, implement, and update individualized social service care plans.
- Provide emotional support, counseling, and crisis intervention to residents and families.
- Assist residents and families with adjustment to illness, disability, placement, and long-term care living.
- Identify psychosocial concerns and coordinate appropriate interventions.
- Advocate for resident rights, dignity, privacy, and self-determination.
- Participate in resident care conferences and interdisciplinary team meetings.
- Monitor residents for signs of abuse, neglect, exploitation, depression, anxiety, or psychosocial decline and report concerns according to facility policy.
- Assist with advance directives, guardianship concerns, and end-of-life planning when appropriate.
Discharge Planning & Care Coordination
- Coordinate safe and effective discharge planning processes.
- Collaborate with hospitals, physicians, home health agencies, hospice providers, dialysis centers, transportation providers, and community agencies.
- Arrange referrals and resources for residents transitioning to home or alternate levels of care.
- Ensure discharge documentation and resident/family education are completed timely and accurately.
- Participate in insurance-related discharge planning discussions as needed.
Family & Resident Relations
- Maintain regular communication with residents and responsible parties.
- Address resident and family concerns promptly and professionally.
- Assist with conflict resolution and grievance management.
- Educate residents and families on resident rights, facility policies, and available services.
- Promote resident and family satisfaction through effective communication and support.
Regulatory & Documentation Responsibilities
- Maintain accurate, timely, and compliant documentation in the medical record.
- Ensure compliance with federal, state, local, and facility regulations, including CMS requirements.
- Participate in quality assurance and performance improvement activities.
- Assist during surveys and audits by providing requested documentation and information.
- Maintain confidentiality of resident information in accordance with HIPAA regulations.
Administrative & Team Responsibilities
- Participate in facility committees and meetings as assigned.
- Collaborate effectively with nursing, therapy, dietary, activities, and administration departments.
- Support facility initiatives related to resident-centered care and quality outcomes.
- Maintain current knowledge of community resources and long-term care regulations.
- Perform other duties as assigned.
Qualifications
- Bachelor's degree in Social Work (BSW) required; Master's degree in Social Work (MSW) preferred.
- Current state Social Work licensure or certification preferred or required based on state regulations.
- Minimum of one (1) year experience in healthcare, skilled nursing, long-term care, rehabilitation, or hospital setting preferred.
- Knowledge of CMS regulations, discharge planning processes, and resident rights.
- Strong communication, organizational, and interpersonal skills.
- Ability to work independently and collaboratively within an interdisciplinary team.
- Ability to manage multiple priorities in a fast-paced environment.
- Proficient in electronic medical records and basic computer applications.
Physical Requirements
- Ability to sit, stand, walk, bend, and move throughout the facility for extended periods.
- Ability to lift, push, or pull up to 25 pounds occasionally.
- Ability to communicate effectively with residents, families, staff, and external providers.
Work Environment
- Skilled nursing and rehabilitation facility environment.
- Frequent interaction with residents, family members, healthcare professionals, and visitors.
Schedule
- Full-time position.
- Weekday schedule with occasional evenings, weekends, or holidays as needed to support resident care and facility operations.
Key Competencies
- Compassion and empathy
- Resident advocacy
- Crisis intervention
- Communication and conflict resolution
- Time management and organization
- Critical thinking and problem-solving
- Team collaboration
- Professionalism and confidentiality
Benefits
- Competitive compensation
- Health, dental, and vision insurance
- Paid time off and holiday pay
- Retirement plan options
- Continuing education opportunities
- Supportive team environment
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