Social Worker (License Req)

Social Worker - Nursing Home

Position Summary

The Social Worker is responsible for providing psychosocial support, advocacy, assistance with financial resoures for residents in a nursing home or long-term care setting. This role helps residents and their families cope with emotional, social, financial, and adjustment issues related to aging, illness, disability, and long-term care placement. The Social Worker works collaboratively with an interdisciplinary team to ensure residents' rights, well-being, and quality of life are maintained.

Essential Duties and Responsibilities

• Upon admission, check that PASRR is present and follow through on all recommendations, including specialized services such as behavior health, or other support needs. Ensure the need for a new PASRR review is assessed with change of condition, especially psychiatric or cognitive changes. Ensure care plan incorporates all PASRR recommendations.
• Ensure Level of Care is completed for any Medicaid or pending patient. Ensure LOC tracker and update on a weekly basis to Administrator.
• Conduct psychosocial assessments for residents upon admission.
• Complete accurate and timely MDS assessments. Ensure accurate coding, timely completion per MDS calendar, regulatory compliance and follow-up with MDS related quality measures.
• Develop, implement, and update individualized care plans addressing residents' social and emotional needs. Ensure care plans are updated timely following any incident or change.
• Provide counseling emotional support to residents and family members. Collaborate with psychiatric practitioners as appropriate.
• Assist residents and families with adjustment to long-term care placement, illness, disability, and end-of-life concerns.
• Coordinate discharge planning with Interdisciplinary team. Utilize Discharge Calendar in Census Pro to ensure and monitor so that discharges are appropriately distributed throughout the month. Calendars should be updated daily. Ensure residents have reached their maximum medical improvement, and discharge goals are achieved to reduce avoidable readmissions to hospital and/or facility.
• Facilitate communication between residents, families, healthcare providers, and community agencies.
• Advocate for residents' rights, dignity, and quality of life.
• Assist residents and families in accessing community resources, financial assistance programs, and supportive services.
• Address concerns regarding abuse, neglect, exploitation, or other resident welfare issues according to facility policies and regulations.
• Participate in interdisciplinary team meetings and contribute to resident care planning.
• Maintain accurate and timely documentation in residents' medical records.
• Assist with advance directives, guardianship issues, and healthcare decision-making processes as appropriate.
• Ensure compliance with Ombudsman Portal. Ensure each involuntary transfer and discharge is electronically reported in the CT LTCOP portal. There must be monthly reporting of all hospitalizations and same day submission for each discharge.
• Ensure compliance with federal, state, and local regulations governing long-term care facilities.

Required Qualifications

• Bachelor's degree in Social Work (BSW) or a related field; Master's degree in Social Work (MSW) preferred.
• Experience working with older adults, long-term care, healthcare, rehabilitation, or geriatric populations preferred.
• Knowledge of Medicare, Medicaid, long-term care regulations, and community resources.
• Strong interpersonal, counseling, and communication skills.
• Ability to work effectively with residents, families, healthcare professionals, and community agencies.
• Proficient in electronic medical records and documentation.

Knowledge, Skills, and Abilities

• Understanding of psychosocial issues affecting elderly and disabled populations.
• Ability to maintain confidentiality and exercise professional judgment.
• Excellent organizational and time-management skills.
• Ability to work independently and as part of a multidisciplinary team.
• Compassion, empathy, and cultural sensitivity.

Physical Requirements

• Ability to move throughout the facility and attend meetings with residents and staff.
• Ability to sit, stand, walk, bend, and lift light materials as needed.
• Ability to communicate effectively in person and by telephone.

Work Environment

• Skilled Nursing facility
• Frequent interaction with residents, families, healthcare providers, and regulatory agencies.
• Exposure to emotionally challenging situations involving illness, disability, grief, and end-of-life care.

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