Job Description

The Social Worker is responsible for supporting the psychosocial, emotional, and discharge planning needs of residents in a skilled nursing facility. This position serves as an advocate for residents and families while coordinating services that promote resident rights, quality of life, dignity, and emotional well-being. The Social Worker collaborates with the interdisciplinary team to ensure residents receive appropriate support, resources, and care planning throughout their stay.

Essential Duties and Responsibilities

Resident Care & Support

• Complete psychosocial assessments for residents upon admission, quarterly, annually, and with significant changes.
• Develop, implement, and update individualized social service care plans.
• Provide emotional support, counseling, and crisis intervention to residents and families.
• Assist residents and families with adjustment to illness, disability, placement, and long-term care living.
• Identify psychosocial concerns and coordinate appropriate interventions.
• Advocate for resident rights, dignity, privacy, and self-determination.
• Participate in resident care conferences and interdisciplinary team meetings.
• Monitor residents for signs of abuse, neglect, exploitation, depression, anxiety, or psychosocial decline and report concerns according to facility policy.
• Assist with advance directives, guardianship concerns, and end-of-life planning when appropriate.

Discharge Planning & Care Coordination

• Coordinate safe and effective discharge planning processes.
• Collaborate with hospitals, physicians, home health agencies, hospice providers, dialysis centers, transportation providers, and community agencies.
• Arrange referrals and resources for residents transitioning to home or alternate levels of care.
• Ensure discharge documentation and resident/family education are completed timely and accurately.
• Participate in insurance-related discharge planning discussions as needed.

Family & Resident Relations

• Maintain regular communication with residents and responsible parties.
• Address resident and family concerns promptly and professionally.
• Assist with conflict resolution and grievance management.
• Educate residents and families on resident rights, facility policies, and available services.
• Promote resident and family satisfaction through effective communication and support.

Regulatory & Documentation Responsibilities

• Maintain accurate, timely, and compliant documentation in the medical record.
• Ensure compliance with federal, state, local, and facility regulations, including CMS requirements.
• Participate in quality assurance and performance improvement activities.
• Assist during surveys and audits by providing requested documentation and information.
• Maintain confidentiality of resident information in accordance with HIPAA regulations.

Administrative & Team Responsibilities

• Participate in facility committees and meetings as assigned.
• Collaborate effectively with nursing, therapy, dietary, activities, and administration departments.
• Support facility initiatives related to resident-centered care and quality outcomes.
• Maintain current knowledge of community resources and long-term care regulations.
• Perform other duties as assigned.

Qualifications

• Bachelor’s degree in Social Work (BSW) required; Master’s degree in Social Work (MSW) preferred.
• Current state Social Work licensure or certification preferred or required based on state regulations.
• Minimum of one (1) year experience in healthcare, skilled nursing, long-term care, rehabilitation, or hospital setting preferred.
• Knowledge of CMS regulations, discharge planning processes, and resident rights.
• Strong communication, organizational, and interpersonal skills.
• Ability to work independently and collaboratively within an interdisciplinary team.
• Ability to manage multiple priorities in a fast-paced environment.
• Proficient in electronic medical records and basic computer applications.

Physical Requirements

• Ability to sit, stand, walk, bend, and move throughout the facility for extended periods.
• Ability to lift, push, or pull up to 25 pounds occasionally.
• Ability to communicate effectively with residents, families, staff, and external providers.

Work Environment

• Skilled nursing and rehabilitation facility environment.
• Frequent interaction with residents, family members, healthcare professionals, and visitors.

Schedule

• Full-time position.
• Weekday schedule with occasional evenings, weekends, or holidays as needed to support resident care and facility operations.

Key Competencies

• Compassion and empathy
• Resident advocacy
• Crisis intervention
• Communication and conflict resolution
• Time management and organization
• Critical thinking and problem-solving
• Team collaboration
• Professionalism and confidentiality

Benefits

• Competitive compensation
• Health, dental, and vision insurance
• Paid time off and holiday pay
• Retirement plan options
• Continuing education opportunities
• Supportive team environment

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