Social Worker

The Social Services Designee is responsible for coordinating and overseeing the continuum of care for residents. This includes assessment, planning, implementation, coordination, monitoring, and evaluation of services to meet the residents' needs. The Social Services Designee ensures that residents receive the appropriate services and care, fostering an environment that supports their well-being and enhances their quality of life. This position will report to Licensed Social Worker for review of Clinical needs, documentation review and oversight.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Assessment and Admissions Conduct comprehensive initial assessments for new admissions, including medical, psychological, and social needs. Develop and implement individualized care plans in collaboration with the interdisciplinary team. Participate in pre-admission screenings and admissions process to ensure appropriate placement and services. May serve as backup for Admissions process. Care Coordination Coordinate all aspects of resident care, including medical treatments, therapy, and social services. Act as a liaison between residents, families, healthcare providers, and facility staff. Schedule and lead care plan meetings with residents, families, and the interdisciplinary team. Monitoring and Evaluation Monitor residents' progress and adjust care plans as necessary. Conduct regular reviews and updates of care plans to reflect residents' changing needs and goals. Evaluate the effectiveness of care plans and interventions, making modifications as needed. Maintain accurate and up-to-date documentation of assessments, interventions, and interactions with residents and families in compliance with regulatory standards and facility policies. Develop and implement discharge plans, ensuring a smooth transition to home, another care facility, or hospice care. Coordinate post-discharge services, such as home health care, follow-up appointments, and community resources. Educate residents and families on discharge plans and ensure they have the necessary resources and information. Connecting residents and their families with community resources, support groups, and other services that may benefit their overall well-being. Documentation and Compliance Will meet monthly with Licensed Social Worker to review documentation and performance requirements. Maintain accurate and detailed documentation of assessments, care plans, interventions, and outcomes. Ensure compliance with all state and federal regulations, as well as facility policies and procedures. Participate in audits, surveys, and quality improvement initiatives. Resident and Family Support Provide empathetic and professional support and counseling to residents and their families regarding care plans, treatment options, and transitions. Provide crisis intervention and support during difficult situations, such as family conflicts, bereavement, or sudden changes in health status. Address and resolve concerns and complaints from residents and families promptly and effectively. Educate residents and families about the facility's services, residents rights, and available community resources. Collaborate with the interdisciplinary team, including nurses, therapists, dietitians, and social workers, to ensure cohesive and comprehensive care. Participate in regular team meetings to discuss resident progress, care plans, and any issues or concerns, to include monthly QUAPI, Care Plan and 72 Hour Meetings as scheduled. Provide training and support to staff on case management processes and best practices. Additional duties as assigned

JOB QUALIFICATIONS

Bachelors or Associates degree in Nursing, Social Work, or a related healthcare field. Valid state licensure as a Registered Nurse (RN), Licensed Practical Nurse (LPN) or Licensed Clinical Social Worker (LCSW), or equivalent, if required. Minimum of 2 years of experience in case management, preferably in a long-term care or skilled nursing facility highly preferred. Strong assessment and care planning skills. Excellent communication and interpersonal skills. Ability to work effectively in a multidisciplinary team. Strong organizational and time-management abilities. Proficiency in electronic health records (EHR) and documentation practices. Knowledge of state and federal regulations related to long-term care.

OTHER REQUIREMENTS

Participates in (or conducts) company-sponsored training to safeguard against improper use and disclosure of resident's protected health information. Monitors and ensures compliance with company policies, procedures and state and federal law.

PHYSICAL DEMANDS AND ENVIRONMENT

Employee is occasionally exposed to blood or other body fluids, fumes or airborne particles and toxic or caustic chemicals. In compliance with applicable law, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position. Standing - Occasionally Sitting - Frequently Walking - Frequently Use Hands/Fingers to handle or feel - Frequently Climbing or Balance - Occasionally Stoop, Kneel, Crouch, or Crawl - Occasionally #J-18808-Ljbffr Pinewood Nursing Home