Position Summary
The Nurse Case Manager / Social Services Coordinator is responsible for coordinating resident care while also providing social services support to residents and their families. This position serves as a key liaison between residents, families, nursing staff, physicians, interdisciplinary team members, and outside service providers.
The Nurse Case Manager will assist with psychosocial needs, care coordination, discharge planning, family communication, resident advocacy, and community resource referrals while maintaining a strong focus on quality of care, resident rights, and regulatory compliance.
Essential Duties and ResponsibilitiesCase Management & Care Coordination
- Coordinate and monitor resident care needs throughout the resident's stay.
- Participate in interdisciplinary care plan meetings and ensure resident needs and preferences are addressed.
- Collaborate with nursing, therapy, dietary, activities, administration, physicians, and other members of the interdisciplinary team.
- Monitor changes in resident condition and communicate significant concerns to the appropriate clinical team members.
- Assist with coordinating physician appointments, specialty services, transportation, and outside healthcare services.
- Follow up on hospitalizations, emergency room visits, and significant changes in resident status.
- Maintain accurate and timely documentation in the resident medical record.
Social Services Responsibilities
- Serve as a primary point of contact for residents and families regarding psychosocial concerns and care-related needs.
- Conduct resident interviews and assist in identifying emotional, social, financial, and environmental needs.
- Provide support to residents experiencing adjustment difficulties, grief, anxiety, depression, family concerns, or changes in independence.
- Advocate for resident rights, dignity, preferences, and quality of life.
- Assist residents and families with identifying and accessing appropriate community resources.
- Provide referrals to community agencies and other supportive services when appropriate.
- Assist with addressing resident grievances and concerns and escalate issues as necessary.
- Maintain appropriate confidentiality and protect resident privacy.
Discharge Planning
- Begin discharge planning early in the resident's stay and update plans as resident needs change.
- Coordinate discharge needs with residents, families, physicians, nursing, therapy, DME providers, home health agencies, hospice, and other community resources.
- Assist residents and families in understanding discharge instructions, medications, appointments, equipment, transportation, and available services.
- Participate in post-discharge follow-up as appropriate.
- Document discharge planning activities and barriers.
Family & Resident Relations
- Maintain regular communication with residents and responsible parties.
- Respond to questions and concerns in a professional, timely, and compassionate manner.
- Assist families in understanding the resident's plan of care and available services.
- Facilitate family meetings when needed.
- Promote positive relationships between residents, families, and facility staff.
- Assist with difficult conversations and coordinate appropriate clinical or administrative follow-up.
Regulatory & Compliance
- Maintain compliance with federal, state, and facility requirements related to resident rights, social services, care planning, discharge planning, and documentation.
- Participate in surveys, audits, quality improvement activities, and corrective action plans as requested.
- Ensure documentation is complete, accurate, timely, and consistent with facility policies.
- Maintain knowledge of applicable long-term care regulations and standards of practice.
Additional Responsibilities
- Participate in Quality Assurance and Performance Improvement (QAPI) initiatives.
- Assist with obtaining advance directives, powers of attorney, guardianship documentation, and other appropriate legal or healthcare documents.
- Assist with identifying residents who may need additional psychosocial or behavioral support.
- Coordinate with hospice, home health, behavioral health, community agencies, and other outside providers.
- Perform other duties as assigned by the Administrator or Director of Nursing.
Qualifications
- Current LVN/LPN license in the State of Texas.
- Experience in skilled nursing, long-term care, rehabilitation, case management, discharge planning, or social services preferred.
- Strong knowledge of resident rights and long-term care regulations.
- Excellent communication and interpersonal skills.
- Ability to work effectively with residents, families, physicians, and interdisciplinary team members.
- Strong organizational and documentation skills.
- Ability to handle sensitive situations with professionalism, compassion, and discretion.
- Experience with electronic medical records preferred.
Key Competencies
- Resident advocacy
- Case management
- Care coordination
- Discharge planning
- Family communication
- Conflict resolution
- Critical thinking
- Documentation
- Interdisciplinary collaboration
- Compassion and professionalism
- Regulatory compliance
Physical Requirements
The employee must be able to perform the essential functions of the position, including frequent interaction with residents and staff, walking throughout the facility, sitting and standing for extended periods, and occasionally assisting with resident-related activities as permitted by licensure and facility policy.
Note: This position is intended to provide nursing case management and social-services coordination. Clinical nursing duties must remain within the employee's current Texas nursing license and scope of practice.
Job Type: Full-time
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Experience:
- Nurse Care Management: 1 year (Required)
License/Certification:
Work Location: In person
