Social Services Director; LSW

Outfield Healthcare Partners is seeking a compassionate and experienced Social Services Director (Licensed Social Worker) to join our skilled nursing facility team in Indianapolis, IN. The Social Services Director is responsible for providing comprehensive social work services, psychosocial assessments, care planning, discharge planning, and resident advocacy to support the emotional, social, and psychological well‑being of our residents.

This position works closely with nursing, rehabilitation, activities, dietary, and administration teams to provide resident‑centered care while ensuring compliance with CMS regulations, state requirements, federal guidelines, and professional social work standards
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The ideal candidate will have experience in skilled nursing, long‑term care, geriatric social work, behavioral health, case management, and interdisciplinary healthcare teams
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• Current licensed, certified, or registered Social Worker credential in the state of practice required.
• Bachelor’s Degree in Social Work (BSW) or a related Human Services field from an accredited college or university required, including but not limited to:
• Sociology
• Psychology
• Rehabilitation Counseling
• Special Education
• Related Human Services disciplines
• Minimum of one (1) year of supervised social work experience in a healthcare setting working directly with geriatric populations preferred.
• Experience working in a skilled nursing facility (SNF), long‑term care, nursing home, rehabilitation center, or senior living environment preferred.
• Knowledge and experience with:
• Minimum Data Set (MDS)
• Resident assessments
• Care planning
• Discharge planning
• Resident rights
• PASARR documentation
• Psychosocial services
• CMS and state survey requirements

• Complete comprehensive social histories, psychosocial assessments, and resident evaluations to identify social, emotional, psychological, and behavioral needs.
• Participate in the Minimum Data Set (MDS) process, including completing applicable sections and using assessment information to guide individualized care planning.
• Develop, implement, and monitor individualized social service care plans that identify resident needs, goals, interventions, and outcomes.
• Maintain accurate and timely documentation in accordance with federal and state regulations, company policies, and facility standards, including:
• Social service assessments
• Social service progress notes
• Care plans
• Advanced directives
• PASARR documentation
• Discharge planning records
• Behavior tracking
• Psychosocial monitoring
• Provide emotional support, counseling, and therapeutic interventions to help residents adjust to:
• Long‑term care placement
• Changes in health status
• Loss of independence
• Personal and emotional challenges
• Advocate for resident rights and support each resident’s right to self‑determination and informed decision‑making.
• Document resident refusals of services, educate residents and families regarding available alternatives, and involve appropriate team members as needed.
• Provide support and education to residents, families, and significant others regarding facility services, care options, community resources, and healthcare decisions.
• Coordinate the resident discharge planning process, including referrals to appropriate home care services, community resources, and outside agencies.
• Collaborate with the interdisciplinary team to identify and address psychosocial needs and promote resident quality of life.
• Work with residents, families, significant others, and staff to encourage self‑advocacy and improve overall resident satisfaction and care outcomes.
• Promote and protect resident rights while identifying, reporting, and assisting with prevention of abuse, neglect, and exploitation in accordance with regulations and professional…