Social Services & Resident Advocacy Coord.

SOUTHERN INYO HEALTHCARE DISTRICT•Lone Pine, CA

10d•$35 - $42•Onsite

About The Position

Serves as the District’s formally designated social services representative for its 33-bed skilled nursing facility. The role provides and coordinates medically related social services to support each resident’s highest practicable physical, mental, and psychosocial well-being. Responsibilities include social services assessments and documentation; identifying psychosocial needs and barriers; participating in resident-centered care planning and interdisciplinary activities; advocating for resident rights; coordinating discharge planning and transitions; connecting residents with community resources and public benefits; assisting with advance directives; and promptly escalating safety, abuse, neglect, and resident-rights concerns. The coordinator works collaboratively with nursing, medical staff, rehabilitation, dietary, activities, administration, residents, families, representatives, community agencies, and the Long-Term Care Ombudsman. The role requires sound judgment, discretion, compassion, strong documentation and communication skills, and adherence to applicable federal and California requirements, SIHD policies, HIPAA, confidentiality, and professional boundaries. Social services duties take priority over other assignments when delay could affect residents’ psychosocial needs, well-being, or access to services. Protected time and qualified backup coverage are established and reviewed by facility leadership. The position is primarily indoors in a skilled nursing facility. It involves frequent sitting, occasional walking and standing, hand use for writing and computer work, and frequent hearing, speaking, and reading. Occasional lifting or carrying of items up to approximately 10 pounds may be required. The incumbent may encounter residents or family members who are upset or hostile and may be exposed to infectious materials; standard precautions and appropriate protective equipment are required. Reasonable accommodation will be considered consistent with applicable requirements.

Requirements

One of the following education and experience pathways: a bachelor’s degree in social work or a human services field; or an associate degree or equivalent plus at least one year of experience in social services, case management, human services, or a long-term-care or health-care setting.
Complete an SIHD Human Resources- and Administrator-approved Social Services Designee certification or training program within six months of hire, unless already holding an equivalent qualification; completion is an employment expectation unless SIHD formally approves an exception.
Satisfactory completion of employment conditions under HR-032, including criminal background clearance as required by California law and consistent with HR-028 and HR-029, drug testing, tuberculosis and other required health clearance, physical exam, and satisfactory references.
Satisfactory exclusion/sanction screening, as applicable under HR-030.
Ability to meet applicable CPR/BLS and other certification, immunization, or health-clearance requirements for long-term-care personnel.
Working knowledge of social services principles, psychosocial assessment, and resident-centered care planning.
Knowledge of long-term-care environments and the needs of older adults and residents with physical, cognitive, and behavioral-health conditions.
Knowledge of resident rights, advocacy, advance directives, surrogate decision-making, and conservatorship concepts.
Knowledge of discharge planning, community resources, county and public-benefit programs, Medicare, and Medi-Cal.
Knowledge of relevant federal and California SNF regulations, mandatory reporting, survey processes, confidentiality, HIPAA, and professional boundaries.
Ability to build respectful relationships with residents, families, and representatives, including in difficult or emotional situations; advocate professionally; identify psychosocial barriers; coordinate resources; facilitate interdisciplinary communication; document accurately and on time; manage sensitive information; communicate with county and community agencies; recognize and promptly escalate issues; organize work under regulatory deadlines; and work as a team member while following SIHD policies.
Working knowledge of federal and California SNF requirements for social services, resident rights, grievances, advance directives, discharge planning, and abuse reporting.
Working knowledge of the electronic health record and social services documentation requirements.
The incumbent may not use the title “Social Worker” or provide services reserved for licensed or credentialed professionals unless holding the required license or credential.

Nice To Haves

Bachelor’s degree in social work (BSW), Master of Social Work (MSW), Associate Clinical Social Worker (ASW), or Licensed Clinical Social Worker (LCSW) credential.
Two or more years of supervised social work experience in a SNF, hospital, or other health-care setting working directly with individuals.
Current California RN or LVN license, particularly for case-management and care-coordination work.
Experience with MDS assessments, including interview components, care planning, and discharge planning.
Knowledge of Medicare, Medi-Cal, SSI/SSA, Veterans benefits, advance directives, and conservatorship processes.
Experience with the Long-Term Care Ombudsman Program, mandated-reporter processes, and CDPH/CMS survey readiness.
Experience in a rural or small-facility setting.
Bilingual ability in a language spoken by SIHD residents and families.

Responsibilities

Complete required social services interviews and written assessments for new residents within applicable timeframes and contribute to comprehensive assessments.
Identify residents’ psychosocial needs, strengths, preferences, concerns, barriers, support systems, and discharge goals, including social, financial, family, environmental, and community factors.
Complete assigned assessment interview components when trained; update assessments quarterly, after significant changes, and as needs arise; document interventions and follow-up in the medical record.
Write timely, accurate, signed progress notes at the frequency required by applicable regulations and SIHD policy.
Participate in resident care-plan meetings and interdisciplinary activities, providing social services information and recommendations.
Develop or contribute to resident-centered social services goals and interventions with residents, families, representatives, physicians, the Director of Nursing, and the care team.
Coordinate with nursing, rehabilitation, dietary, activities, medical staff, and administration, including arranging meeting coverage when unavailable.
Help the medical staff and care team understand residents’ social, psychological, and emotional needs.
Advocate for residents and help them communicate concerns, preferences, and requests to District personnel.
Inform residents and representatives about resident rights, personal and property rights, and available resources.
Assist with complaints and grievances, document concerns and actions taken, and report them to the Director of Nursing and grievance official under SIHD policy.
Support resident participation in care decisions as permitted by the resident’s condition and applicable requirements; assist with Long-Term Care Ombudsman referrals and communications.
Participate in admissions, readmissions, room moves, and resident and family inquiries as assigned.
Begin discharge planning at admission and continue throughout the stay; identify barriers to safe discharge and develop plans with residents, families, representatives, and the interdisciplinary team.
Coordinate referrals, follow-up appointments, transportation, housing-related needs, and transfer of services to community providers; document discharge planning and final discharge status.
Support required resident screening and referral processes, such as PASRR, as assigned.
Maintain working relationships with county and community agencies, nonprofit organizations, community health workers, and Veterans services, and maintain a current community-resource file.
Assist residents in accessing housing, food, transportation, financial assistance, and other community resources.
Assist residents and authorized representatives with public-benefit applications and documentation, including SSI/SSA, disability, and Medi-Cal-related matters, within the position’s scope.
Provide information about Medicare, Medi-Cal, and other financial assistance programs; refer complex eligibility or legal matters to qualified professionals or agencies.
Assist with resident trust or account processes according to SIHD policy.
Assist residents in accessing and completing advance directive documents and coordinate required witnessing or validation processes.
Identify residents needing assistance to understand or communicate advance-care-planning preferences and coordinate with appropriate representatives.
Coordinate with authorized representatives, agents under durable powers of attorney, conservators, family members, and county or court representatives, and document communications.
Escalate legal or decision-making questions to the Administrator or a qualified professional.
Provide supportive interventions within the position’s qualifications to help residents adjust to admission, health changes, changes in living environment, and discharge.
Identify psychosocial concerns requiring referral to behavioral-health, clinical, or other professional services; make referrals and document follow-up while maintaining professional boundaries and scope of practice.
Immediately report suspected abuse, neglect, exploitation, rights violations, or unsafe discharge to the Director of Nursing and Administrator, and complete legally required reports to the Ombudsman, law enforcement, Adult Protective Services, and California Department of Public Health, including Form SOC 341 where applicable.
Do not independently investigate matters outside assigned authority; maintain confidentiality during reporting and investigation.
Support CDPH and CMS survey readiness, participate in survey activities and corrections as assigned, and report compliance concerns through the SIHD escalation process.
Immediately report incidents and accidents and participate in fire-safety and disaster-preparedness drills.
Participate in staff orientation, in-service education related to resident psychosocial needs and rights, and quality assurance and performance-improvement activities as assigned.
Serve on assigned committees and complete in-service training before tasks that may involve exposure to blood, body fluids, infectious materials, or hazardous chemicals.
Perform other duties reasonably related to the position and consistent with qualifications and department needs.
Comply with HIPAA and SIHD privacy and security policies; access, use, and disclose protected health information only as authorized and necessary for assigned duties.
Comply with SIHD personnel, safety, infection-control, and compliance policies and promptly report suspected privacy, security, or compliance concerns.
Complete SIHD-designated SNF training within the first six months of employment, including abuse and neglect prevention and reporting, resident rights, dementia care, behavioral health, infection prevention, HIPAA, and compliance and ethics.
Complete initial training and competency validation under HR-038 and department orientation under HR-036.