Primary Purpose:
The Social Worker provides comprehensive psychosocial support, assessment, and discharge planning services for residents on the short-term rehabilitation unit, managing a caseload of residents designated within the community. This role serves as the primary point of contact for residents and families throughout the long term or short term rehabilitation stay, coordinates all aspects of discharge planning, and collaborates closely with the Interdisciplinary Team to ensure safe, timely, and appropriate transitions of care.
Qualifications/Skills Needed:
- Bachelor's or Master's degree in Social Work (BSW/MSW) from an accredited program required or related human services field
- Current state social work licensure (e.g., LSW, LBSW, LMSW) required or in progress per state requirements
- 1-3 years of social work experience in a skilled nursing, healthcare, or long-term care setting preferred
- Experience with short-term rehab discharge planning strongly preferred
Primary Duties (Essential Functions) include but are not limited to:
Psychosocial Assessment & Care Planning
- Complete comprehensive social histories, care plans, MOS assessments, and trauma care assessments for residents within the community
- Initiate psychiatric referrals as clinically indicated
- Maintain an active caseload within the community as designated
Discharge Planning & Care Coordination
- Coordinate discharge planning for short-term rehab residents, including identifying and securing alternative placement options
- Arrange home health and caregiver services to support safe discharge
- Schedule physician follow-up appointments as part of the discharge plan
- Order and coordinate medical equipment, including oxygen, nebulizers, Accu-Chek machines, wound vac units, and tube feed supplies
- Coordinate referrals and scheduling for home dialysis clinic services
- Initiate referrals to and coordinate services with Hosparus
- Issue Notice of Discharge to residents and families and process all related appeal documentation
Interdisciplinary Collaboration
- Facilitate care plan meetings between resident families and the Interdisciplinary Team
- Present thorough, up-to-date knowledge of each resident and their discharge plan at the weekly Interdisciplinary Team meeting
- Collaborate professionally across departments, multi-tasking and prioritizing a high-volume caseload
Resident & Family Relations
- Serve as the primary point of contact between residents/families and the facility
- Communicate with residents and families on an ongoing basis regarding care concerns, treatment updates, and discharge planning
- Provide ongoing support through services within the facility or community as needed for all residents.
Documentation & Insurance Coordination
- Maintain accurate and up-to-date documentation in the Electronic Medical Record
- Provide insurance updates and communicate resident status to insurance companies