Social Worker for Long Term Care Skilled Nursing Facility

Social Worker - Long-Term Care Skilled Nursing Facility
Position Overview
The Social Worker plays a vital role in supporting the emotional, psychosocial, and discharge planning needs of residents in a skilled nursing facility. This position ensures compliance with CMS Requirements of Participation, HHSC state regulations, and facility policies while promoting resident rights, dignity, and quality of life.

Key Responsibilities
Resident Assessment & Care Planning
• Complete timely and accurate psychosocial assessments, including MDS Section D, E, and Q, in accordance with CMS guidelines.
• Participate in interdisciplinary care plan meetings, ensuring resident-centered goals and interventions.
• Identify and address psychosocial, behavioral, emotional, and environmental needs.
Regulatory Compliance
• Ensure all social services documentation meets CMS and HHSC regulatory requirements.
• Maintain compliance with resident rights, grievance processes, and abuse/neglect reporting standards.
• Support facility readiness for state and federal surveys, including providing documentation and participating in interviews.
Resident & Family Support
• Provide counseling, crisis intervention, and emotional support to residents and families.
• Facilitate communication between residents, families, and the care team.
• Assist residents with advance directives, decisionmaking support, and guardianship processes when needed.
Discharge Planning & Care Transitions
• Coordinate safe and appropriate discharge plans, including community resources, home health, hospice, or other placements.
• Communicate with hospitals, agencies, and families to ensure continuity of care.
• Provide education on postdischarge needs and available support services.
Documentation & Case Management
• Maintain accurate, timely, and compliant progress notes, assessments, and care plan updates.
• Track and respond to resident grievances, documenting resolutions per regulatory standards.
• Support residents with financial, insurance, and Medicaid/Medicare-related questions within scope.
Behavioral Health & Supportive Services
• Assist in developing and implementing behavioral intervention plans.
• Collaborate with psychiatric providers and therapy teams as needed.
• Monitor residents for signs of depression, anxiety, trauma, or cognitive decline and report concerns promptly.

Qualifications
• Bachelor's degree in Social Work (BSW) required; Licensed Social Worker (LSW or LBSW) in Texas preferred.
• Experience in long-term care, skilled nursing, or healthcare social services strongly preferred.
• Knowledge of CMS Requirements of Participation, HHSC LTC regulations, and MDS processes.
• Strong communication, documentation, and advocacy skills.
• Ability to work compassionately with older adults and individuals with complex medical needs.

What We Offer
• Competitive compensation and benefits package.
• Supportive interdisciplinary team environment.
• Opportunities for professional development and regulatory training.
• A meaningful role improving the lives of residents and families.