Job Summary:
The Social Worker is responsible for ensuring that the social and emotional needs of the residents are met, as well as coordinating the discharge of residents.
Job Duties:

• Complete an initial interview/assessment to identify any social work needs or problems, take a social history that includes family, education and occupational background, adjustment and level of functioning, interests, support systems and other observations.
• Complete assigned sections of MDS, develop a plan of care within 14 days; document all in resident record. Enters timely and complete progress notes into the medical record to document any issues handled with a resident and/or family.
• Prepare and implement a comprehensive Discharge Plan that addresses patient’s needs and update as needed.
• Coordinate initial Care Conference within 10 days of admission, and coordinate additional quarterly care conferences throughout the stay, communicating with resident and family.
• Coordinate successful discharges by clearly communicating with physician, nurse manager, rehab director, resident, and family/other applicable parties regarding the resident’s needs post discharge. A successful discharge will be defined as one where services and equipment are set up and ready to start on the date of discharge, the resident does not return to the hospital within 90 days, and the resident/family feel they have been cared for, well-educated about care, and have made a smooth transition to the discharge destination.
• Receive resident and family concerns/grievances and respond quickly to them. Act as the facilitator to ensure communication between residents, family and staff. Maintains log of grievances and their resolution.
• Provide counseling for residents and families. Communicates with residents and families in a way that conveys caring support with a professional approach.
• Facilitate communication between staff and non-English speaking residents.
• Offer information and help residents and families on obtaining financial assistance and on the meaning of administrative forms and releases to be signed by the resident or family.
• Coordinate the facility’s outreach services to the families of residents.
• Perform advocacy services on behalf of the residents to ensure that concrete needs are met, such as clothing, laundry and the residents’ personal needs allowance, if one is maintained.
• Help residents and families identify and gain access to community services, using resource materials and a knowledge of the residents’ needs and abilities.
• Coordinate clinical social work services to residents as needed and to families if related to issues that directly affect the resident.
• Maintain list of residents electing Hospice care and communicate this list to care team.
• Administer NOMNC and ABN notices in accordance with Medicare and managed care guidelines.
• Administer “Notice of Emergency Transfer” letter to Ombudsman and resident representative.
• Participate in facility QAPI program by presenting an improvement project each month.
• Assist staff in coping with the personal needs and demands of particular residents.
• Spearhead the effort to locate lost items when needed.
• Distribute required letters and information to residents, explaining verbally when necessary.
• Keep up-to-date on current development and communications practices and procedures in the area of Social Work.
• Maintain HIPAA compliance with all communications. Present concise, meaningful written reports and articulate the social/psychological needs of the patients including progress notes.
• Represent the organization in a positive and professional manner to outside organizations and at outside educational functions.
• Ensure compliance with policies and procedures regarding department operations, privacy, fire, safety, and infection control.
• Other duties as assigned.