Syracuse
Job Description Job Title: Social Worker Department: Social Services Reports To: Director of Social Services FLSA Status: Exempt Position Summary The Social Worker is responsible for providing medically related social services to residents in a Skilled Nursing Facility (SNF) to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with federal, state, and local regulations. The Social Worker serves as a resident advocate, supports residents and families through adjustment and transition processes, coordinates discharge planning, and collaborates with the interdisciplinary team to ensure resident-centered care and regulatory compliance. Essential Functions Resident Assessments and Care Planning · Complete psychosocial assessments upon admission, quarterly, annually, and as significant changes occur. · Identify emotional, behavioral, social, financial, and environmental factors impacting resident well-being. · Participate in the development, implementation, and evaluation of individualized care plans. · Attend and contribute to interdisciplinary team meetings and care conferences. · Document assessments, interventions, and progress notes in accordance with facility policy and regulatory requirements. Resident and Family Services · Provide counseling, support, and crisis intervention to residents and families. · Assist residents and families in adapting to placement in the facility, illness, disability, loss, and end-of-life issues. · Educate residents and families regarding resident rights, advance directives, and available community resources. · Address resident and family concerns, grievances, and complaints and facilitate resolution. Admissions and Discharge Planning · Participate in pre-admission screenings and admission processes as assigned. · Coordinate discharge planning from admission through discharge to ensure safe and successful transitions. · Arrange referrals to home health agencies, hospice providers, durable medical equipment suppliers, assisted living facilities, and other community resources as needed. · Collaborate with residents, families, physicians, nursing staff, therapists, and outside agencies to ensure continuity of care. Regulatory Compliance and Resident Rights · Ensure compliance with CMS regulations, state requirements, and facility policies related to social services. · Promote and protect resident rights, dignity, choice, and quality of life. · Assist residents with advance directives and healthcare decision-making documentation. · Support facility survey readiness and participate during state and federal surveys. Behavioral Health and Psychosocial Support · Monitor residents for psychosocial concerns including depression, anxiety, adjustment disorders, behavioral concerns, and social isolation. · Collaborate with psychiatric providers, psychologists, and behavioral health specialists as appropriate. · Develop interventions to address psychosocial and behavioral concerns. · Participate in behavior management and risk reduction planning. Financial and Community Resource Coordination · Assist residents and families with Medicaid applications, financial resource referrals, and insurance-related concerns. · Coordinate access to community programs and supportive services. · Maintain knowledge of local, state, and federal assistance programs available to residents. Qualifications Education · Bachelor's Degree in Social Work (BSW) required. · Master's Degree in Social Work (MSW) preferred. Experience · Minimum one (1) year of social work experience in a healthcare setting preferred. · Experience in skilled nursing, long-term care, rehabilitation, or post-acute care strongly preferred. · Knowledge of discharge planning, case management, and psychosocial assessments. Licensure/Certification · Current Social Work license or certification as required by state law. · Eligibility to practice social work in the state of employment. Knowledge, Skills, and Abilities · Thorough knowledge of CMS regulations and F-Tags related to social services, including F656, F657, F740-F745, and resident rights requirements. · Strong understanding of discharge planning requirements and transition of care processes. · Excellent interpersonal, counseling, conflict resolution, and communication skills. · Ability to maintain confidentiality and exercise professional judgment. · Strong organizational and documentation skills. · Ability to work effectively with residents, families, physicians, and interdisciplinary team members. Physical Requirements · Ability to sit, stand, walk, bend, and reach throughout the workday. · Ability to move throughout the facility to meet with residents and families. · Ability to occasionally lift or carry up to 25 pounds. Working Conditions · Skilled Nursing Facility (SNF) environment. · Frequent interaction with residents, families, visitors, physicians, and staff. · Exposure to emotionally sensitive situations involving illness, loss, family conflict, and end-of-life care. Equal Opportunity Employer: The facility is committed to providing equal employment opportunities and maintaining a diverse and inclusive workplace. Preferred Long-Term Care Experience: Candidates with prior SNF or long-term care experience and knowledge of CMS regulations are strongly preferred. #upstate123