Director of Social Services

COMMONWEALTH CARE OF ROANOKE-posted about 14 hours ago

Full-time • Director

Onsite • Innovation, VA

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JOB SUMMARY: The Director of Social Services and Care Coordination – Other Qualifications is responsible for assessing each resident upon admission, in accordance with mandated assessment schedules and periodically as needed to identify social services needs and initiating and developing an individualized safe transition plan.

Ensures proper PASRR screening documentation is on file for all residents and makes referrals for Level II screenings as indicated.
Leads the Interdisciplinary Safe Transitions Meetings for new admissions and documents as appropriate the results of those STM in the resident record.
Provides residents and/or responsible parties with baseline care plan summary and documents that the summary was provided in the EMR.
With the Interdisciplinary Care Team (IDT), develops, and updates as needed, a plan of care to address identified needs upon admission.
Participates as an essential member of the center’s Interdisciplinary Care Team (IDT) in ongoing development and maintenance of a patient centered plan of care addressing patient/resident’s identified needs throughout the stay and transition plan (if applicable)
Completes care plan reviews for assigned sections of care plan by target date set for care plan reviews.
Ensures residents, their family and/or responsible parties are invited to attend the care conference meetings and maintains evidence of those invitations.
Facilitates and leads care conference meeting and ensures that care conference attendance is documented in the appropriate assessment note in the resident EMR, and ensures all care team members endorse the outcome of the care conference meetings by signing the appropriate care review in the EMR
Coordinates the implementation of the IDT plan of care, ensuring all disciplines are addressing planned interventions to ensure resident/resident’s goals are met and there is a safe transition plan in place to the next level of care, when applicable.
Responsible for the planning and coordination of resident’s safe transition to the next level or site of care.
Responsible for the timely delivery of NOMNC (Generic and Detailed) & ABN notices for Medicare & Managed care beneficiaries, explaining the appeal rights of the beneficiaries, as well as the expedited appeal process.
Assist resident/family in navigating third party payer appeals process when payer decisions are not aligned with resident/resident/family goals, and /or IDT team assessments for care needs or the safe transition to another level of care.
Coordinates the Expedited appeal process for Medicare A type payers when appeals occur including collection of information for submission to reviewing entity.
Appropriately notifies State Ombudsman’s office of all discharges from center according to CCR policy and federal requirements.
Participates in the accurate completion of LTSS Screening (UAI) process in accordance with Virginia LTSS requirements and regulations.
Serves as back up to the Medicaid application and renewal process for appropriate residents. Attends Medicaid pending meetings with Business Office Manager and Administrator as needed.
Serves as center level contact person for third party payer case managers, assisting Central Managed Care Case Managers in assuring all needed information is available for meeting resident/resident’s goals and a safe transition.
Completes all required documentation within required time frames based on regulatory requirements and center guidelines; including but not limited to Psychosocial Assessments, BIMs assessments, quarterly progress notes and episodic progress notes to record encounters and follow-up to issues that impact/potentially impact resident/resident psychosocial well-being.
Completes all appropriate sections of the MDS timely and accurately according to current CMS RAI manual guidance and company procedure, specifically sections C, D, E and Q and any other sections assigned to Social Services. Completes triggered Care Area Assessments (Section V/CAAs) and corresponding care plan development.
Participates in post discharge follow-up call/check per center procedure as deemed necessary to determine success of transition to community/lower level of care and prevent unnecessary re-hospitalization.
Develops, organizes and coordinates available center and community resources to provide the highest quality social services program, while meeting the needs and interests of the residents.
Establishes and/or implements social services and safe transition programs that reflect goals/objectives of the department, maintaining compliance with state, federal and center guidelines.
Conducts routine departmental auditing to ensure compliance with regulatory requirements and company policies.
Supervises, trains and evaluates center Social Services Care Coordination personnel to assure effective and timely intervention in meeting resident’s psychosocial needs.
Provides education to residents and staff regarding Resident Rights, Advanced Directives and advanced care planning to meet regulatory and/or center guidelines.
Maintains a positive working relationship with staff, families and all persons or agencies concerned with the well/being of the resident.
Maintains a positive and effective working relationship with Center, Regional and Corporate staff.
Maintains positive and effective working relationship with CCR Central Managed Care Case Management team.
Manages department budget, ensuring availability of needed resources to meet resident needs.
Coordinates social work student intern’s experiences in the center when appropriate.
Promote and demonstrate a culture of service excellence.
Perform other duties as assigned

Bachelor’s degree in social work or human services appropriate to resident needs or one year supervised experience in social work within the last five years preferred.
Trained in recognizing and assessing the emotional and social, and medical social needs of residents; and is knowledgeable of community agencies and resources available to meet those needs throughout care transitions.
Knowledge of third-party payer requirements for skilled patients and long-term residents.
Knowledge of federal and state regulations and MDS assessments for SNFs.
Strong customer service and leadership skills.
Strong interpersonal and communication skills; both written and verbal.
Proficiency in using Microsoft office programs (Word, Excel, Adobe and PowerPoint).
Must be flexible, detail-oriented, ability to multi-task, meet deadlines and be able to make effective decisions and work as part of a service excellence team.
Standing, walking (or other form of locomotion), and sitting throughout the day
Ability to communicate clearly (speak, hear, and see) applicable to complete job duties
Close contact with coworkers, patient/residents, visitors
Occasional lifting of equipment and supplies (approximately 50 lb. max)

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