Social Worker Skilled and Assisted Living

Social Worker for Skilled and Assisted Living Social Worker – Skilled Nursing (STR) & Memory Care Assisted Living

Hours: 8:30am - 4:30pm

The Social Worker provides psychosocial services to residents and families in accordance with CMS regulations, state requirements, and facility policies across the Continuing Care Retirement Community (CCRC). This position is responsible for all admissions to the Memory Care Assisted Living neighborhood and serves as a backup for admissions in the Short-Term Rehabilitation (STR) Skilled Nursing neighborhood. The Social Worker ensures resident rights, psychosocial well-being, safe transitions of care, discharge planning, and interdisciplinary coordination in compliance with State and Federal Standards.

• Coordinate all admissions into the Memory Care Assisted Living neighborhood
  , including communication with families, referral sources, nursing, administration, and interdisciplinary team members.
• Facilitate the admission process to ensure regulatory compliance, resident safety, and smooth transition into Memory Care.
• Coordinate and complete all psychosocial components of Memory Care admissions.
• Meet with residents and families at admission to assess psychosocial status, adjustment needs, support systems, and advance directives.
• Complete psychosocial assessments and document findings in the electronic medical record (EMR) in accordance with regulatory requirements.
• Educate residents and families regarding resident rights, grievance procedures, and care planning processes.

• Provide coverage for STR admissions as needed and coverage for LTC Social Worker as needed.
• Meet with residents and families at admission and complete required psychosocial assessments and documentation in the electronic medical record (EMR).
• Submit Clinical Updates to Medicare Advantage Plans

• Participate in the MDS process in compliance with CMS requirements.
• Meet with residents due for MDS assessments per the schedule provided by the MDS Nurse.
• Conduct BIMS and Mood (PHQ-9) interviews to assess cognitive status and psychosocial well-being.
• Accurately enter BIMS and PHQ-9 data into assessments within required time frames.
• Document resident encounters and findings in the electronic medical record (EMR).
• Develop, implement, and revise psychosocial care plans based on assessed needs.
• Complete PASRR
• Assist families with Long Term Care Insurance Claims
• Aid families with completing the Medicaid process for LTC.

• Collaborate with the interdisciplinary team to ensure discharge planning begins upon admission and continues throughout the resident’s stay.
• Monitor rehabilitation progress to support appropriate length of stay and level of care determinations.
• Meet with residents and families to discuss discharge options, preferences, and post-discharge needs.
• Arrange and coordinate post-discharge services, including home health therapy, durable medical equipment, transportation, and community resources.
• Obtain physician orders for home health services, face-to-face documentation, and equipment as required.
• Complete discharge summaries and required documentation in the electronic medical record (EMR).
• Communicate discharge plans and updates to nursing, therapy, physicians, and the care plan team.
• Conduct post-discharge follow-up calls to residents and/or families to assess adjustment, identify concerns, and ensure a safe and smooth transition of care.
• Communicate identified post-discharge issues to appropriate team members for follow-up.

• Provide ongoing psychosocial support to residents with cognitive impairment and their families.
• Support families with education, coping, and decision-making related to dementia progression.
• Collaborate with memory care staff to address behavioral, emotional, and social needs.
• Participate in and document care planning activities in the electronic medical record (EMR).
• Complete LTC insurance paperwork and submitting it for the families.
• Obtain…