Licensed Social Worker

Optalis•Bloomfield Hills, MI

5d•Onsite

About The Position

The Social Worker supports the psychosocial, emotional, and discharge-planning needs of residents in a skilled nursing and rehabilitation facility. The role advocates for residents and families and coordinates services that promote resident rights, quality of life, dignity, and emotional well-being. The Social Worker collaborates with the interdisciplinary team to ensure residents receive appropriate support, resources, and care planning throughout their stay. Responsibilities include completing psychosocial assessments; developing and updating individualized social-service care plans; providing emotional support, counseling, and crisis intervention; assisting residents and families with adjustment to illness, disability, placement, and long-term care; and coordinating interventions for psychosocial concerns. The role also supports resident rights and participates in care conferences, discharge planning, family relations, regulatory documentation, quality improvement, and facility initiatives. The position is full-time, with a weekday schedule and occasional evenings, weekends, or holidays as needed to support resident care and facility operations. The work takes place in a skilled nursing and rehabilitation facility, with frequent interaction with residents, families, healthcare professionals, and visitors.

Requirements

Bachelor’s degree in Social Work (BSW) required.
Current state Social Work licensure or certification preferred or required depending on state regulations.
Knowledge of CMS regulations, discharge planning processes, and resident rights.
Strong communication, organizational, and interpersonal skills.
Ability to work independently and collaboratively within an interdisciplinary team.
Ability to manage multiple priorities in a fast-paced environment.
Proficiency in electronic medical records and basic computer applications.
Ability to sit, stand, walk, bend, and move throughout the facility for extended periods.
Ability to lift, push, or pull up to 25 pounds occasionally.
Ability to communicate effectively with residents, families, staff, and external providers.

Nice To Haves

Master’s degree in Social Work (MSW).
At least one year of experience in healthcare, skilled nursing, long-term care, rehabilitation, or a hospital setting.

Responsibilities

Complete psychosocial assessments upon admission, quarterly, annually, and when residents experience significant changes.
Develop, implement, and update individualized social-service care plans.
Provide emotional support, counseling, and crisis intervention to residents and families.
Assist residents and families with adjustment to illness, disability, placement, and long-term care living.
Identify psychosocial concerns and coordinate appropriate interventions.
Advocate for residents’ rights, dignity, privacy, and self-determination.
Participate in resident care conferences and interdisciplinary team meetings.
Monitor for signs of abuse, neglect, exploitation, depression, anxiety, or psychosocial decline, and report concerns according to facility policy.
Assist with advance directives, guardianship concerns, and end-of-life planning when appropriate.
Coordinate safe and effective discharge planning.
Collaborate with hospitals, physicians, home health agencies, hospice providers, dialysis centers, transportation providers, and community agencies.
Arrange referrals and resources for residents transitioning to home or other levels of care.
Ensure discharge documentation and resident and family education are completed accurately and on time.
Participate in insurance-related discharge planning discussions as needed.
Maintain regular communication with residents and responsible parties.
Address resident and family concerns promptly and professionally; assist with conflict resolution and grievance management.
Educate residents and families about resident rights, facility policies, and available services.
Maintain accurate, timely, and compliant medical-record documentation.
Ensure compliance with applicable federal, state, local, and facility regulations, including CMS requirements.
Participate in quality assurance and performance improvement activities.
Assist with surveys and audits by providing requested documentation and information.
Maintain confidentiality of resident information in accordance with HIPAA regulations.
Participate in facility committees and meetings as assigned.
Collaborate with nursing, therapy, dietary, activities, and administration departments.
Support facility initiatives related to resident-centered care and quality outcomes.
Maintain current knowledge of community resources and long-term care regulations.
Perform other duties as assigned.