Social Worker

Position Summary

The Social Worker is responsible for assisting residents and their families with social, emotional, psychosocial, and discharge planning needs throughout their stay in the facility. This position helps ensure residents receive the support, resources, and services needed to maintain the highest practicable level of physical, mental, and psychosocial well-being in accordance with facility policies and state and federal regulations.

Essential Duties and Responsibilities

• Complete psychosocial assessments for residents upon admission, quarterly, annually, and with significant changes as required.
• Assist with care planning and participate in interdisciplinary care plan meetings.
• Coordinate and schedule resident and family care plan meetings as needed.
• Provide emotional support and counseling to residents and families related to adjustment, illness, placement, loss, and other concerns.
• Assist residents and families with advance directives, discharge planning, and long-term placement needs.
• Coordinate discharge planning to ensure safe and effective transitions to home, hospital, assisted living, or other levels of care.
• Serve as a liaison between residents, families, staff, physicians, and outside agencies.
• Investigate, document, and follow up on resident grievances and concerns in a timely manner.
• Assist with allegations of abuse, neglect, exploitation, or behavioral concerns, including required documentation and follow-up.
• Complete and maintain required assessments, audits, and documentation, including but not limited to BIMS, PASRR-related coordination, elopement assessments, and other psychosocial documentation as assigned.
• Participate in PAR meetings, QAPI meetings, risk meetings, and other interdisciplinary meetings as requested.
• Coordinate with auxiliary and community services such as hospice, home health, dialysis, podiatry, optometry, mental health providers, and the ombudsman.
• Assist residents and families with access to community resources, financial resources, counseling services, and other support systems.
• Promote resident rights, dignity, and quality of life at all times.
• Maintain accurate, timely, and thorough documentation in the medical record.
• Ensure compliance with HIPAA, resident confidentiality, and all state and federal regulations related to social services.

Knowledge, Skills, and Abilities

• Knowledge of psychosocial assessment and care planning processes.
• Understanding of resident rights, abuse reporting, grievance procedures, and discharge planning requirements.
• Ability to handle sensitive and emotional situations with professionalism, compassion, and discretion.
• Strong follow-up and problem-solving skills.
• Strong written and verbal communication skills.
• Ability to maintain confidentiality and professional boundaries.

Qualifications

• Bachelor’s degree in Social Work, Human Services, Psychology, Sociology, or related field required.
• Social work experience in a long-term care, skilled nursing, hospital, rehab, or healthcare setting preferred.
• Knowledge of long-term care regulations, resident rights, discharge planning, and psychosocial needs preferred.
• Strong communication, organization, conflict-resolution, and documentation skills.
• Ability to work effectively with residents, families, staff, physicians, and community partners.
• Ability to manage multiple priorities and meet deadlines in a fast-paced environment.
• Ability to maintain confidentiality and professionalism at all times.