Social Worker, Patient​/Health Advocate

Oakhurst Health & Rehab | Fork Union, VA
Skilled Nursing & Rehabilitation

Are you passionate about helping others navigate life’s transitions with compassion, dignity, and support?

Oakhurst Health & Rehab is seeking a compassionate and organized Social Worker to join our interdisciplinary team. In this important role, you’ll advocate for our residents, support families, coordinate resources, and help ensure each resident can achieve and maintain their highest practicable level of physical, mental, and psychosocial well-being.

If you’re a strong communicator who enjoys building relationships and making a meaningful difference in the lives of seniors and their families, we’d love to meet you!

As our Social Worker, you’ll serve as an important connection between our residents, their families, our clinical team, and community resources.

Key responsibilities include:

• Assess residents’ psychosocial needs, cognitive changes, mood concerns, and behavioral needs and coordinate appropriate follow-up.

• Build positive relationships with residents and families while providing support throughout their stay.

• Assist new residents and families during the admission process to promote a smooth transition into the community.

• Coordinate and participate in interdisciplinary care plan meetings.

• Develop and maintain individualized social service assessments, care plans, progress notes, and other required documentation.

• Assist residents and families with discharge planning and coordinate appropriate community services and resources.

• Make referrals to community agencies, consultants, and other resources based on individual resident needs.

• Educate residents and families regarding available Medicare and Medicaid benefits and other potential resources for long-term care.

• Advocate for resident rights, dignity, independence, choice, and self-determination.

• Facilitate communication between residents, families, legal representatives, and members of the interdisciplinary care team.

• Support residents and families with advance directives and healthcare decision-making.

• Coordinate with psychiatric and behavioral health professionals as appropriate.

• Monitor and document psychosocial, cognitive, and behavioral changes.

• Assist residents in accessing opportunities for community involvement, resident council participation, and voting when requested.

• Provide education and support to staff regarding resident rights, psychosocial needs, behavioral symptoms, advance directives, and related topics.

• Participate in Quality Assurance and Performance Improvement initiatives.

• Attend facility meetings, care conferences, and required committees.

• Work collaboratively with Nursing, Admissions, Activities, Rehabilitation, Business Office, and other departments to provide resident-centered care.

• High school diploma or equivalent required.

• Bachelor’s degree in Social Work, Human Services, or a related field preferred.

• Previous experience working with seniors or in a healthcare setting preferred.

• Two years of supervised social work experience working directly with geriatric clients in a healthcare setting is highly desirable.

• Skilled nursing, long-term care, rehabilitation, assisted living, or healthcare experience is a plus.

• Strong communication, organization, documentation, and interpersonal skills.

• Ability to work collaboratively as part of an interdisciplinary team.

• Compassionate, resident-focused approach with a strong commitment to resident rights and dignity.

• Knowledge of Medicare, Medicaid, discharge planning, community resources, and long-term care regulations is a plus.

At Oakhurst Health & Rehab
, our residents are at the center of everything we do. Our Social Worker plays an essential role in ensuring residents and families feel heard, supported, informed, and respected throughout their journey with us.

You’ll have the opportunity to collaborate with an experienced healthcare team while making a meaningful impact on residents and their families every day.

If you’re looking for a role where your compassion, communication skills, and ability to connect people with the resources they need can truly make a difference, we want to hear from you.