Licensed Social Worker

Licensed Social Worker (LSW)

The Licensed Social Worker (LSW) is responsible for the psychosocial assessment, planning, and coordination of social services for residents of the skilled nursing facility. This position ensures that each resident's emotional, social, and discharge planning needs are addressed in accordance with federal and state regulations, facility policy, and professional social work standards. The LSW works collaboratively with the interdisciplinary team (IDT), residents, families, and community resources to promote resident-centered care and safe, effective transitions.

Essential Duties and Responsibilities

Resident Assessment & Care Planning

• Complete psychosocial assessments for all new admissions within required timeframes per CMS guidelines (MDS Section Q, E, and related items).

• Participate in care conferences and IDT meetings; represent the social services perspective in care plan development and revision.

• Identify residents at risk for depression, anxiety, cognitive decline, abuse, neglect, or exploitation and initiate appropriate interventions.

• Document social service assessments, progress notes, and care plan updates in the electronic health record (EHR) in a timely, accurate manner.

Discharge Planning & Transitions of Care

• Initiate discharge planning at or before admission in collaboration with the resident, family, care team, and payer source.

• Coordinate safe discharges to home, assisted living, or other care settings, including arranging home health, DME, transportation, and community-based supports.

• Facilitate communication with managed care organizations, ACOs, and hospital case management teams to support efficient and compliant transitions.

• Assist with prevention of unnecessary rehospitalizations through proactive identification of clinical and social risk factors.

Resident & Family Support

• Serve as a primary point of contact and advocate for residents and families regarding rights, grievances, and facility concerns.

• Facilitate family meetings and difficult conversations related to goals of care, level of care changes, and end-of-life planning.

• Connect residents and families with community resources including financial assistance, legal aid, mental health services, and support groups.

• Assist residents with advance directive completion, including Living Wills, Healthcare Surrogate designations, and DNR/POLST forms.

Regulatory Compliance & Quality

• Ensure social services documentation meets federal (F-tag), state, and facility standards; participate in mock surveys and audit preparation.

• Maintain working knowledge of OBRA regulations, resident rights, HIPAA, APS/CPS reporting obligations, and state licensure requirements.

• Track and report social service quality indicators; contribute to QAPI initiatives and performance improvement projects.

• Complete required sections of the Minimum Data Set (MDS) accurately and within CMS-mandated assessment reference dates.

Interdisciplinary Collaboration

• Partner with nursing, therapy, dietary, activities, and administration to ensure a whole-person approach to resident care.

• Serve as a resource for staff on social and behavioral concerns, de-escalation strategies, and trauma-informed care practices.

• Coordinate with psychiatric/behavioral health consultants, ombudsman, and external agencies as needed.

Minimum Qualifications

Education

• Bachelor's degree in Social Work (BSW) required; Master's degree in Social Work (MSW) preferred.

Licensure

• Current, valid Licensed Social Worker (LSW) or Licensed Clinical Social Worker (LCSW) license in the state of employment — required.

• Licensure must be maintained in good standing throughout employment; renewal responsibilities rest with the employee.

Experience

• Minimum one (1) year of social work experience in a long-term care, post-acute, or healthcare setting preferred.

• Experience with MDS documentation, care planning software, and electronic health records is strongly preferred.

Knowledge, Skills & Abilities

• Working knowledge of CMS F-tags, OBRA mandates, resident rights, and state SNF regulations.

• Strong assessment, crisis intervention, and clinical documentation skills.

• Effective communicator with residents, families, staff, and external stakeholders across all levels.

• Proficiency with electronic health record systems; experience with PointClickCare, MatrixCare, or similar platforms preferred.

• Ability to manage multiple priorities, maintain confidentiality, and work independently within an interdisciplinary team.

Physical Requirements

The position requires the ability to:

• Sit, stand, and walk for extended periods throughout the facility.

• Occasionally lift or assist with materials up to 25 lbs.

• Navigate a clinical environment including resident rooms, common areas, and nursing stations.

• Operate standard office and computer equipment for documentation and communication tasks.

Working Conditions

• Indoor clinical environment within a licensed skilled nursing facility.

• Regular exposure to residents with complex medical, behavioral, and psychosocial needs.

• Weekend and holiday coverage may be required on a rotational basis.

• On-call responsibilities as assigned per facility policy.

Acknowledgment

This job description is intended to describe the general nature and level of work being performed by employees assigned to this position. It is not intended to be a complete or exhaustive list of all responsibilities, duties, and skills required. The facility reserves the right to modify this job description at any time based on operational needs, regulatory changes, or other legitimate business reasons.

Employee Signature

Date: _______________

Administrator / Supervisor Signature

Date: _______________