Social Worker

Document care plans and services provided in the resident's medical record in accordance with state


and federal regulatory requirements and company policies. Ensure all entries are accurate, timely,


and descriptive of the services provided.
• Complete assigned sections on the Minimal Data Set (MDS) in timely manner.
• Arranges and obtains needed durable medical equipment, clothing, and personal items for residents.
• Partners with the clinical team in training staff on resident's behaviors and appropriate behavioral


interventions.
• Coordinates home health, hospice, and supportive services, including making referrals to and


obtaining services from outside agencies as needed.
• Participates in leadership team by actively contributing to decision making, grievance follow-up,


building and company-wide initiatives and attending leadership meetings such as Stand-Up, Quality


Assurance Performance Improvement (QAPI), and other meetings as required.
• Performs other duties as assigned.


SOCIAL SERVICES
• Act as resident advocate by ensuring that services are provided in the resident's best interest and


educating on residents' rights.
• Meet with all new admissions to discuss and document the resident's psychosocial history and


identify the current psychosocial needs.
• Communicate regularly with the resident and resident's family regarding resident needs.
• Ensure comprehensive psychosocial care plans are in place for each resident and are completed


within the required timeframe and updated quarterly and as needed.
• Arrange ancillary services including, but not limited to, dental, ophthalmology, and audiology services

Initiates discharge planning upon admission.
• Coordinates with the resident and/or resident's representative(s), the interdisciplinary team, and


physician to determine appropriate discharge plans for transitioning the patient home or to an


optimal care environment.
• Schedules and directs timely and efficient discharge planning meetings for all new admissions.
• Utilizes scheduled administrative meetings, the Recovery Map, care plan meetings, internal and


community resources to facilitate education and planning that provides the patient and family the


support needed in order to resume life in the community or at a lower level of care.
• Assesses the patient's support systems and home situation to assist in decision-making regarding


the patient's discharge plan and discharge needs.
• Facilitates effective bed management by strategic evaluation and internal arrangement of center


beds in order to maximize the availability of transition and extended care services.
• Adheres to company procedures for initiating internal transfers, and documents room/roommate


change processes including notifications, transfers, interventions, and outcomes in the patient's


medical record.
• Coordinate with center's Business Office to ensure timely issuance of Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN).
• Provide center case management for managed care residents by collecting and submitting required


resident assessments and progress updates to insurance companies.

PREREQUISITES
• Bachelor's degree in social work, human services, or related field preferred.
• Two (2) years of experience in Social Work or related role
• Experience in skilled nursing or healthcare environment preferred.


PREFERRED SKILLS
• Strong interpersonal skills and ability to communicate effectively.
• Strong organizational and analytical skills.
• Strong written and verbal communication skills.
• Ability to work independently with limited supervision.