Social Work & Discharge Planning Assistant

Medical Facilities of America (MFA)

Medical Facilities of America (MFA) is a leading provider of advanced and transitional healthcare services for patients needing post-acute, skilled, and rehabilitative care. MFA’s in‑house Life Works Rehab offers individualized inpatient rehabilitation for patients recovering from surgeries, strokes, or injuries, with a strong focus on motivating patients to regain independence and enjoy their life again. The company is dedicated to utilizing state‑of‑the‑art equipment and innovative therapeutic methods to ensure faster and more complete recoveries.

With facilities located across various settings, including urban, rural, beach, and mountain areas, MFA is committed to delivering exceptional care in diverse communities.

The Social Work & Discharge Planning Assistant is responsible for assisting in the operation of the center’s Social Work & Discharge Planning department; ensuring that the social, psychological, and physical needs of all residents in the center are being met. This position is responsible for coordinating all aspects of the patient’s safe discharge from the center back to home or a lower level of care.

• Document care plans and services provided in the resident’s medical record in accordance with state and federal regulatory requirements and company policies. Ensure all entries are accurate, timely, and descriptive of the services provided.
• Complete assigned sections on the Minimal Data Set (MDS) in a timely manner.
• Arrange and obtain needed durable medical equipment, clothing, and personal items for residents.
• Partner with the clinical team in training staff on resident’s behaviors and appropriate behavioral interventions.
• Coordinate home health, hospice, and supportive services, including making referrals to and obtaining services from outside agencies as needed.
• Participate in leadership team by actively contributing to decision making, grievance follow-up, building and company‑wide initiatives and attending leadership meetings such as Stand‑Up, Quality Assurance Performance Improvement (QAPI), and other meetings as required.
• Perform other duties as assigned.
• Act as resident advocate by ensuring that services are provided in the resident’s best interest and educating on residents’ rights.
• Meet with all new admissions to discuss and document the resident's psychosocial history and identify the current psychosocial needs.
• Communicate regularly with the resident and resident’s family regarding resident needs.
• Ensure comprehensive psychosocial care plans are in place for each resident and are completed within the required timeframe and updated quarterly and as needed.
• Arrange ancillary services including, but not limited to, dental, ophthalmology, and audiology services.
• Coordinate with the resident and/or resident’s representative(s), the interdisciplinary team, and physician to determine appropriate discharge plans for transitioning the patient home or to an optimal care environment.
• Schedule and direct timely and efficient discharge planning meetings for all new admissions.
• Utilize scheduled administrative meetings, the Recovery Map, care plan meetings, internal and community resources to facilitate education and planning that provides the patient and family the support needed in order to resume life in the community or at a lower level of care.
• Assess the patient’s support systems and home situation to assist in decision‑making regarding the patient’s discharge plan and discharge needs.
• Facilitate effective bed management by strategic evaluation and internal arrangement of center beds in order to maximize the availability of transition and extended care services.
• Adhere to company procedures for initiating internal transfers, and document room/roommate change processes including notifications, transfers, interventions, and outcomes in the patient’s medical record.
• Coordinate with center’s Business Office to ensure timely issuance of Notice of Medicare Non‑Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN).
• Provide center case management for managed care residents by collecting and submitting required resident assessments and progress updates to insurance companies.

• Preferred:
  Bachelor’s or Master’s degree in social work.
• Must be social work licensure‑eligible in Maryland.
• Two (2) years of experience in Social Work or related role.
• Experience in skilled nursing or healthcare environment preferred.

• Strong interpersonal skills and ability to communicate effectively.
• Strong organizational and analytical skills.
• Strong written and verbal communication skills.
• Ability to work independently with limited supervision.

Entry level

Part‑time

Administrative

Hospitals and Health Care