Social Worker

Job Title: Social Worker
Department: Social Services
Reports To: Director of Social Services
FLSA Status: Exempt

Position Summary

The Social Worker is responsible for providing medically related social services to residents in a Skilled Nursing Facility (SNF) to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with federal, state, and local regulations. The Social Worker serves as a resident advocate, supports residents and families through adjustment and transition processes, coordinates discharge planning, and collaborates with the interdisciplinary team to ensure resident-centered care and regulatory compliance.

Essential Functions

Resident Assessments and Care Planning

·         Complete psychosocial assessments upon admission, quarterly, annually, and as significant changes occur.

·         Identify emotional, behavioral, social, financial, and environmental factors impacting resident well-being.

·         Participate in the development, implementation, and evaluation of individualized care plans.

·         Attend and contribute to interdisciplinary team meetings and care conferences.

·         Document assessments, interventions, and progress notes in accordance with facility policy and regulatory requirements.

Resident and Family Services

·         Provide counseling, support, and crisis intervention to residents and families.

·         Assist residents and families in adapting to placement in the facility, illness, disability, loss, and end-of-life issues.

·         Educate residents and families regarding resident rights, advance directives, and available community resources.

·         Address resident and family concerns, grievances, and complaints and facilitate resolution.

Admissions and Discharge Planning

·         Participate in pre-admission screenings and admission processes as assigned.

·         Coordinate discharge planning from admission through discharge to ensure safe and successful transitions.

·         Arrange referrals to home health agencies, hospice providers, durable medical equipment suppliers, assisted living facilities, and other community resources as needed.

·         Collaborate with residents, families, physicians, nursing staff, therapists, and outside agencies to ensure continuity of care.

Regulatory Compliance and Resident Rights

·         Ensure compliance with CMS regulations, state requirements, and facility policies related to social services.

·         Promote and protect resident rights, dignity, choice, and quality of life.

·         Assist residents with advance directives and healthcare decision-making documentation.

·         Support facility survey readiness and participate during state and federal surveys.

Behavioral Health and Psychosocial Support

·         Monitor residents for psychosocial concerns including depression, anxiety, adjustment disorders, behavioral concerns, and social isolation.

·         Collaborate with psychiatric providers, psychologists, and behavioral health specialists as appropriate.

·         Develop interventions to address psychosocial and behavioral concerns.

·         Participate in behavior management and risk reduction planning.

Financial and Community Resource Coordination

·         Assist residents and families with Medicaid applications, financial resource referrals, and insurance-related concerns.

·         Coordinate access to community programs and supportive services.

·         Maintain knowledge of local, state, and federal assistance programs available to residents.

Qualifications

Education

·         Bachelor's Degree in Social Work (BSW) required.

·         Master's Degree in Social Work (MSW) preferred.

Experience

·         Minimum one (1) year of social work experience in a healthcare setting preferred.

·         Experience in skilled nursing, long-term care, rehabilitation, or post-acute care strongly preferred.

·         Knowledge of discharge planning, case management, and psychosocial assessments.

Licensure/Certification

·         Current Social Work license or certification as required by state law.

·         Eligibility to practice social work in the state of employment.

Knowledge, Skills, and Abilities

·         Thorough knowledge of CMS regulations and F-Tags related to social services, including F656, F657, F740-F745, and resident rights requirements.

·         Strong understanding of discharge planning requirements and transition of care processes.

·         Excellent interpersonal, counseling, conflict resolution, and communication skills.

·         Ability to maintain confidentiality and exercise professional judgment.

·         Strong organizational and documentation skills.

·         Ability to work effectively with residents, families, physicians, and interdisciplinary team members.

Physical Requirements

·         Ability to sit, stand, walk, bend, and reach throughout the workday.

·         Ability to move throughout the facility to meet with residents and families.

·         Ability to occasionally lift or carry up to 25 pounds.

Working Conditions

·         Skilled Nursing Facility (SNF) environment.

·         Frequent interaction with residents, families, visitors, physicians, and staff.

·         Exposure to emotionally sensitive situations involving illness, loss, family conflict, and end-of-life care.

Equal Opportunity Employer: The facility is committed to providing equal employment opportunities and maintaining a diverse and inclusive workplace.

Preferred Long-Term Care Experience: Candidates with prior SNF or long-term care experience and knowledge of CMS regulations are strongly preferred.

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