Social Worker (Full-Time)

THE ROUSE ESTATE

POSITION PROFILE

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TITLE: Social Worker

DEPARTMENT: Resident Centered Services

SUPERVISOR: Director of Resident Centered Services

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OBJECTIVE:

The Social Worker provides comprehensive psychosocial services to residents in the skilled nursing facility (SNF) setting. This role ensures person-centered care planning, regulatory compliance, discharge coordination, advocacy, and support for residents and families to promote quality of life and successful transitions of care.

ESSENTIAL RESPONSIBILITIES

1. Comprehensive Psychosocial Assessment

Conduct timely psychosocial assessments upon admission, quarterly, annually, and with significant change in condition. Identify resident strengths, needs, behavioral considerations, coping patterns, support systems, and discharge potential.

2. Individualized Care Planning & MDS Participation

Lead and actively participate in the interdisciplinary care plan process. Complete required MDS sections, CAAs, data gathering, and supporting documentation in compliance with CMS, Medicare, and Medical Assistance regulations. Notify residents and responsible parties of care plan meetings and encourage participation.

3. Resident & Family Adjustment Support

Provide counseling, education, and guidance to residents and families to support adjustment to placement, illness progression, behavioral changes, and end-of-life considerations. Facilitate communication among residents, families, physicians, and the interdisciplinary team.

4. Discharge Planning & Community Coordination

Develop and implement safe, appropriate discharge plans. Coordinate referrals to hospice, mental health services, durable medical equipment providers, community agencies, and other post-acute resources to ensure continuity of care.

5. Behavioral Health & Intervention Support

Collaborate with nursing leadership, mental health professionals, and the interdisciplinary team to develop and implement behavior management interventions and non-pharmacological strategies that promote resident dignity and safety.

6. Resident Rights, Grievances & Advocacy

Promote and protect resident rights in accordance with federal and state regulations. Report allegations of abuse or neglect immediately per policy. Assist with grievance follow-up, missing item investigations, voting opportunities, and Resident Council participation.

7. Documentation & Regulatory Compliance

Maintain accurate, timely, and confidential documentation in the medical record. Ensure compliance with Department of Health, Department of Aging, CMS guidelines, and facility policies. Participate in survey readiness activities, quality assurance chart audits, and Quality of Life surveys.

8. Culture & Quality of Life Initiatives

Promote culture change principles and household engagement. Participate in facility activities and programs designed to enhance resident self-esteem, autonomy, and overall quality of life. Support departmental program development and continuous improvement initiatives.

9. Other Duties as Assigned

Perform additional responsibilities as necessary to support resident care, regulatory compliance, departmental operations, and organizational objectives.

INTERFACE:

INTERNAL: Maintain a calm, supportive presence for residents and families. Develop collaborative relationships across all departments. Foster a positive, professional environment aligned with the mission of The Rouse Estate.

EXTERNAL: Represent the organization positively within the community. Maintain professional relationships with regulatory agencies, community providers, councils, and service organizations. Promote the reputation and mission of The Rouse Estate.

QUALIFICATIONS:

EDUCATION:

• Bachelor’s Degree in Social Work (BSW) or related field required. Must meet state and federal requirements for social services designee in a skilled nursing facility.

EXPERIENCE:

• Minimum two (2) years of experience in healthcare, preferably in long-term care or gerontology, preferred.

SKILLS REQUIRED:

• Strong clinical documentation and assessment skills
• Knowledge of MDS process and regulatory standards
• Effective counseling and crisis intervention skills
• Excellent communication and interpersonal abilities
• Organizational and time-management proficiency
• Ability to manage multiple priorities in a fast-paced environment

SPECIAL QUALIFICATIONS:

• Demonstrated commitment to serving older adults, including individuals with Alzheimer’s disease, dementia, behavioral health conditions, and related disorders
• Ability to work in an environment with potential exposure to communicable diseases
• Emotional resilience and ability to manage challenging resident behaviors professionally
• Adequate vision, hearing, and verbal communication abilities to perform essential job functions

I HAVE READ THE ABOVE JOB DESCRIPTION AND FULLY UNDERSTAND THE REQUIREMENTS SET FORTH THERIN. I HEREBY ACCEPT THE POSITION CASEWORKER AND AGREE TO ABIDE BY THE REQUIREMENTS SET FORTH AND WILL PERFORM ALL DUTIES AND RESPONSIBILITIES TO THE BEST OF MY ABILITY.

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