PT Social Worker Designee - Discharge Planner

Facility: Ovid Healthcare Center

The Social Services Designee / Discharge Planner is responsible for coordinating and facilitating safe, timely, and appropriate discharges for residents of the skilled nursing facility. This role supports residents and families through the discharge process by addressing psychosocial needs, coordinating post-acute service, and ensuring compliance with federal, state, and local regulations. The Social Worker collaborates with the interdisciplinary team to address emotional, social, behavioral, and environmental factors that impact resident care, outcomes, and successful transitions.

Join us with an attractive benefits offering

• Competitive pay
• 401K with matching funds
• Life Insurance
• Employee discounts
• Tuition Reimbursement
• Student Loan Reimbursement

Responsibilities

• Meet with the resident/responsible party at or shortly after admission and provide ongoing follow-up and support through discharge.
• Collaborate with residents, families, physicians, nursing, therapy, and case management to identify discharge needs and appropriate levels of care.
• Arrange post-discharge services including home health, durable medical equipment, hospice, outpatient services, transportation, and community resources.
• Participate in 72-hour care plan meetings, care conferences, discharge planning meetings, and other meetings as assigned.
• Identify and communicate potential barriers to discharge to include but not limited to housing, financial, behavioral health or care giver concerns to the Social Worker.
• Develop an individualized discharge care plan in collaboration with the interdisciplinary team, family, and provider, assuring the resident receives the care and services that will meet their needs in the community.
• Conduct assessments, care planning, interventions, referrals, and case management.
• Provide discharge planning, counseling, and support services in coordination with the interdisciplinary team.
• Contributes to the Resident’s assessment (MDS/CAA’s) and the development of a plan of care.
• Assist residents and families with financial, legal, and community resource referral
• Provide education and counseling regarding treatment options, health care decision-making, and advance directive forms.
• Facilitate admission process by reviewing advance directives, resident rights, and facility policies.
• Provide grief support and counseling as needed.
• Maintain a current list of community resources and facilitate referrals (e.g., home health, hospice, transportation, financial/legal services).
• Maintain accurate, timely, and compliant documentation in accordance with CMS, state regulations, and facility policies.
• Participate in Quality Assurance and Performance Improvement initiatives as assigned.

Education and/or Experience

• High school diploma/GED
• One or more years of experience in discharge planning, case management, or care coordination in a healthcare setting preferred.
• Experience in a skilled nursing facility, post-acute, or long-term care environment preferred.
• Working knowledge of discharge planning regulations, resident rights, and post-acute care resources.

Certificate, Licenses, Registrations

• None

Ciena Healthcare

We are a national organization of skilled nursing, subacute, rehabilitative, and assisted living providers dedicated to achieving the highest standards of care in Michigan and Ohio.

We serve our residents with compassion, concern, and excellence, believing that every one of them is a unique person who deserves our best each day that we care for them. Join us, if you have a passion for improving the lives of those around you and working with others who feel the sam