Social Worker, Patient​/Health Advocate

Up to $30.00 / hour

A transition into skilled nursing - or back home following rehabilitation - affects far more than a resident’s medical care. Residents and families need someone who can help them understand what comes next, identify barriers, coordinate support, and protect dignity throughout the process.

Elderwood is seeking a Social Worker to join the interdisciplinary team at our skilled nursing and rehabilitation community. In this role, you will advocate for residents, address psychosocial and emotional needs, support families through complex decisions, and help coordinate successful admissions, care plans, transfers, and discharges.

This is visible, meaningful social work. You will help new residents adjust to their surroundings, connect individuals and families with needed services, and ensure each resident’s voice, preferences, independence, and quality of life remain central to their care.

You understand that successful social work in skilled nursing requires both empathy and follow-through. You can build trust with residents and families while remaining organized, documenting thoroughly, and coordinating effectively across multiple disciplines.

You are comfortable navigating sensitive conversations, competing priorities, and complex care transitions—and you remain focused on practical solutions that support the resident.

Help Residents and Families Understand What Comes Next.

What You’ll Be Responsible For

• Manage an assigned social work caseload and serve as a consistent resource for residents and their families.

• Welcome and help orient new residents, supporting their emotional and social adjustment to the community.

• Identify psychosocial, emotional, mental health, and practical needs and coordinate access to appropriate services and resources.

• Participate in the development and review of individualized care plans with the interdisciplinary care team.

• Advocate for residents’ preferences, individuality, independence, dignity, and right to participate in decisions about their care.

• Support residents and families through changes in condition, difficult decisions, transfers, and transitions to another level of care.

• Participate actively in discharge planning and help coordinate safe, appropriate transitions.

• Complete required admission and discharge assessments, including SCREEN documentation when applicable.

• Provide supportive individual or group counseling and connect residents and families with financial, community, or personal resources within the scope of the position.

• Maintain accurate, timely documentation in accordance with facility, departmental, and regulatory requirements.

• Collaborate with nursing, rehabilitation, medical providers, admissions, and other facility departments to address residents’ physical, emotional, and social needs.

• Participate in staff education and in-service programs as requested.

• Bachelor’s degree in Social Work or a related human services field from an accredited institution. Related fields may include psychology, sociology, gerontology, rehabilitation counseling, special education, or another qualifying discipline.

• At least one year of supervised social work experience in a healthcare setting working directly with individuals.

• Previous casework experience.

• Strong communication, documentation, organization, and interdisciplinary collaboration skills.

• Genuine interest in working with older adults and supporting residents and families through healthcare transitions.

• Valid driver’s license and a driving record that meets company requirements.

• Ability to…