Clin Social Worker

Overview

The Social Worker provides psychosocial support to residents in attaining or maintaining their highest practicable well-being. This position plays a key role in patient assessment, care planning, coordination of services and when applicable discharge planning. The social worker collaborates closely with the interdisciplinary team, family, and community partners to ensure ethical, and patient-centered care in compliance with federal, state, and facility regulations.

Responsibilities

• Resident Assessment & Care Planning: Complete social service assessments and contribute to individualized care plans, ensuring goals support each resident’s emotional, mental, and psychosocial needs. Encourage residents and families to participate in care planning meetings.
• Admissions & Discharge Support: Assist with preadmission evaluations and required screenings. Coordinate safe and effective discharge planning, including arranging community services, follow-up care, and access to financial, legal, and social resources.
• Resident Advocacy & Support: Identify and communicate residents’ social, emotional, and psychological needs to the care team. Advocate for residents’ rights and dignity, assist with grievances, and ensure access to appropriate mental health and psychosocial resources.
• Documentation & Compliance: Maintain timely, accurate, complete, and professional documentation. Ensure compliance with federal and state regulations, facility policies, HIPAA, Title 22, CMS conditions of participation and social work ethical standards.Advance Care Planning:Support residents and representatives in understanding and completing Advance Directives. Ensure staff are aware of residents’ code status and end-of-life preferences.
• Safety, Confidentiality & Reporting: Protect resident privacy, follow infection control and safety procedures, and report incidents such as abuse, neglect, policy violations, or workplace injuries according to facility guidelines.
• Resident Engagement & Daily Support: Obtain social histories, assist residents with personal needs (e.g., supplies, clothing, transportation), support communication needs, and act as a resource for behavioralinterventions.
• Interdepartmental Collaboration: Coordinate Social Services activities with other departments and participate in care plan meetings, psychotropic reviews, and required facility meetings. Provides education and support to staff regarding psychosocial issues, trauma-informed care, and patient rights. Supports the facilities Quality Assurance and Performance Improvement (QAPI) initiatives by participating in audits and data collection as needed.
• Professional Development & Leadership: Complete all required training and continuing education. Assist with policy development and assume leadership of the Social Services Department in the Director’s absence.

Qualifications

Skills / Knowledge / Experience

• Minimum 1 year of experience in social services and discharge planning.• Strong knowledge of CMS Conditions of Participation, CDPH standards, and Title 22 requirements.• Proficient in Google Docs. Experience in working with an EMR/PCC system preferred.• Excellent verbal, written, and interpersonal communication skills; ability to exercise sound judgment.• Demonstrated leadership, organization, teamwork, and problem-solving abilities.• Ability to work effectively in a multidisciplinary, fast-paced environment and maintain composure under stress.• Ability to make independent decisions and interact tactfully with residents, families, staff, and regulatory personnel.• Capable of coordinating meetings, setting goals, and managing tasks efficiently.