Medical Social Worker

1. Position Summary

The Social Worker at Serenity Oaks IRF provides psychosocial assessment, counseling, and discharge planning services to rehabilitation inpatients and their families. This clinician is a core member of the IDT and addresses barriers to recovery including psychological, social, financial, and environmental factors that may affect rehabilitation outcomes. The Social Worker coordinates community resources, facilitates family meetings, and ensures each patient has a comprehensive, safe discharge plan aligned with their individual goals and needs.

2. Essential Functions & Responsibilities

· Performs timely patient evaluations, reassessments, and psychosocial assessments; identifies and documents functional, psychosocial, emotional, financial, and environmental needs or barriers that may affect rehabilitation, recovery, and discharge planning.

· Develops and implements an individualized therapy plan consistent with physician orders, patient goals, and the interdisciplinary plan of care.

· Participates in interdisciplinary team conferences to communicate progress, barriers, functional status, goals, and discharge needs.

· Facilitate patient and family meetings to address adjustment to disability, coping strategies, and care goals.

· Provide individual counseling and crisis intervention to patients and family members as needed.

· Coordinate discharge planning including identification of appropriate post-acute placement, home care services, and community supports.

· Assist with applications for entitlement programs including Medicaid, Social Security, community aid, and disability benefits.

· Collaborate with case management on insurance authorizations, LOS management, and payor-specific discharge requirements.

· Refer patients and families to community resources including mental health services, substance abuse programs, and support groups.

· Document all social work interventions, contacts, and outcomes accurately and timely in the EHR.

· Participate in CIHQ program evaluation activities and social work quality improvement initiatives.

· Comply with mandatory reporting obligations for abuse, neglect, exploitation, and domestic violence.

· Maintains patient safety and complies with infection prevention, confidentiality/HIPAA, and hospital policies and procedures.

· Maintains required licensure, competencies, and continuing education and practices in accordance with applicable CMS IRF requirements, federal and state regulations, and professional standards of practice.

3. Education & Experience Requirements

· Required: Bachelor of Social Work (BSW) from a CSWE-accredited program; Master of Social Work (MSW) strongly preferred.

· Preferred: MSW from a CSWE-accredited program.

· Preferred: One (1) or more years of social work experience in a healthcare, rehabilitation, or post-acute setting.

· Preferred: Experience with IRF or acute inpatient rehabilitation patient populations.

4. Licensure, Certification & Registration Requirements

· Required: Current Louisiana social work licensure appropriate to degree level: Licensed Bachelor Social Worker (LBSW) or Licensed Master Social Worker (LMSW), issued by the Louisiana State Board of Social Work Examiners (LSBSWE).

· Preferred: Licensed Clinical Social Worker (LCSW) from LSBSWE.

· Required: Current BLS/CPR certification (AHA or Red Cross).

· Required: Louisiana social work license verified through LSBSWE prior to and throughout employment.

5. Knowledge, Skills & Abilities

· Knowledge of biopsychosocial assessment and person-in-environment practice frameworks.

· Understanding of adjustment to disability, grief, and coping processes in rehabilitation populations.

· Knowledge of community resources, entitlement programs, and post-acute care options in Louisiana.

· Familiarity with CMS IRF CoPs and CIHQ standards related to social services.

· Effective counseling, crisis intervention, and family facilitation skills.

· Knowledge of mandatory reporting requirements under Louisiana law.

· Proficiency with EHR documentation in a healthcare setting.

· Ability to navigate complex family dynamics and multi-system care coordination.

· Knowledge of advance directives, healthcare proxies, and ethical decision-making frameworks.

· Commitment to culturally competent, trauma-informed social work practice.

6. Physical Demands & Working Conditions

· Primarily office and patient room environment; frequent walking throughout facility.

· Occasional lifting up to 20 lbs.

· Primarily sedentary during documentation, counseling, and family meetings.

· Exposure to patients with infectious conditions; PPE as appropriate.

· Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in accordance with the Americans with Disabilities Act.

7. Compliance & Regulatory Acknowledgements

· Comply with HIPAA Privacy and Security Rules in all psychosocial documentation.

· Adhere to Serenity Oaks Corporate Compliance Program and Code of Conduct.

· Mandatory reporter under Louisiana law for abuse, neglect, exploitation, and domestic violence.

· Participate in CIHQ program evaluation and accreditation activities.

· Comply with CMS IRF CoPs related to social services and discharge planning.

· Maintain compliance with Louisiana LSBSWE licensure requirements

8. Equal Employment Opportunity Statement

Serenity Oaks Inpatient Rehabilitation Facility is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law.

Work Location: In person