Social Services & Resident Advocacy Coord.

SOUTHERN INYO HEALTHCARE DISTRICT•Lone Pine, CA

9d•Onsite

About The Position

Serves as the District’s formally designated social services representative for its 33-bed Skilled Nursing Facility (SNF), providing and coordinating medically related social services so residents can attain or maintain the highest practicable physical, mental, and psychosocial well-being. The role conducts social-services assessments; identifies psychosocial needs and barriers; participates in care planning and interdisciplinary activities; advocates for resident rights; leads social-services aspects of discharge planning and transitions; coordinates community resources and public-benefit support; assists with advance directives; and promptly escalates safety, abuse, neglect, and 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 position requires sound judgment, discretion, compassion, and strong documentation and communication skills. The incumbent is the SNF’s designated social services representative, confirmed in writing by the Administrator and Director of Nursing. Required social services duties take priority over other assignments when delay could affect residents’ psychosocial needs, well-being, or access to services. The Administrator and Director of Nursing establish and document protected social-services time based on census and resident needs, review it at least quarterly, and maintain a written coverage plan naming a qualified backup. The Director of Nursing monitors completion and documentation of required duties at least monthly and reports gaps to the Administrator. The position is non-exempt and hourly, with a stated pay range of $35.00–$42.00. It is based primarily indoors at the Southern Inyo Healthcare District Skilled Nursing Facility. The incumbent must comply with HIPAA, privacy and security rules, personnel and safety policies, infection-control requirements, and applicable federal and California SNF regulations. The incumbent may not use the title “Social Worker” or provide services reserved for licensed or credentialed professionals unless properly licensed or credentialed.

Requirements

One of the following education and experience pathways: a bachelor’s degree in social work or a human-services field (such as sociology, gerontology, psychology, rehabilitation counseling, or special education); 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 a Social Services Designee certification or training program approved by SIHD Human Resources and the Administrator within six months of hire under an HR- and DON-approved development plan, unless an equivalent qualification is already held; completion is an employment expectation unless SIHD formally approves an exception.
Satisfactory completion of employment conditions under HR-032, including required criminal-background clearance, drug test, tuberculosis and other health clearances, physical examination, and satisfactory references.
Satisfactory exclusion/sanction screening, as applicable under HR-030.
Ability to meet CPR/BLS and other certification, immunization, or health-clearance requirements applicable to long-term-care personnel.
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, including Medicare and Medi-Cal.
Knowledge of federal and California SNF regulations relevant to social services, mandatory reporting, and 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 and identify psychosocial barriers; coordinate resources and facilitate interdisciplinary communication.
Ability to document interventions accurately and on time; manage sensitive and confidential information; communicate with county and community agencies; recognize and promptly escalate matters requiring professional, administrative, or regulatory attention; organize work and meet time and regulatory deadlines; and work as a team member while following SIHD policies.
Must not use the title “Social Worker” or provide services reserved for licensed or credentialed professionals without the required license or credential.
Complete initial training and competency validation under HR-038 and department orientation under HR-036.
The work environment may involve residents with cognitive, medical, or behavioral needs; upset or hostile residents or family members; and exposure to infectious materials, requiring standard precautions and appropriate protective equipment.

Nice To Haves

Bachelor’s degree in Social Work (BSW), Master of Social Work (MSW), Associate Clinical Social Worker (ASW) credential, or Licensed Clinical Social Worker (LCSW) credential, which also supports meeting the federal Qualified Social Worker standard and California supervision requirements.
At least two 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 aspects of the position.
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 the required social services interview and written assessment for each new resident within applicable federal, California, and SIHD timeframes, and contribute to the comprehensive assessment.
Identify each resident’s psychosocial needs, strengths, preferences, concerns, barriers, support systems, and discharge goals, including social, financial, family, environmental, and community factors.
Complete assigned assessment interview components, such as mood, cognition, and discharge-planning sections, when trained and assigned.
Update assessments quarterly, after significant changes, and as needs arise; document interventions and follow-up in the resident’s medical record.
Write timely, accurate, signed progress notes at the frequency required by California regulations and SIHD policy.
Participate in resident care-plan meetings and interdisciplinary team 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, and arrange 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 appropriate 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; and report as required by SIHD policy.
Support resident participation in care decisions to the extent 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, continue it 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 activities 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-resources file.
Help residents access housing, food, transportation, financial assistance, and other community resources; assist residents and authorized representatives with public-benefit applications and documentation within the position’s scope.
Provide information about Medicare, Medi-Cal, and other financial assistance programs, referring complex eligibility or legal matters to qualified professionals or agencies; assist with resident trust or account processes under SIHD policy.
Assist residents with accessing and completing advance-directive documents and coordinate required witnessing or validation processes.
Identify residents needing help understanding or communicating advance-care-planning preferences; coordinate with authorized representatives, agents under durable powers of attorney, conservators, family members, and county or court representatives; document communications and escalate legal or decision-making questions.
Provide supportive interventions within the incumbent’s qualifications to help residents adjust to admission, health or living-environment changes, and discharge; identify concerns requiring referral to qualified professionals, make referrals, and document follow-up.
Immediately report suspected abuse, neglect, exploitation, rights violations, or unsafe discharge to the Director of Nursing and Administrator, and complete required reports to the Ombudsman, law enforcement, Adult Protective Services, and the California Department of Public Health as required by law, including Form SOC 341 where applicable.
Maintain confidentiality during reporting and investigations, and do not independently investigate matters outside assigned authority.
Support readiness for CDPH and CMS surveys, participate in survey activities and corrections as assigned, and report compliance concerns through SIHD’s escalation process.
Immediately report incidents and accidents and participate in fire-safety and disaster-preparedness drills.
Participate in staff orientation and in-service education related to resident psychosocial needs and rights, quality-assurance and performance-improvement activities, assigned committees, and required in-service training before tasks involving potential exposure to blood, body fluids, infectious materials, or hazardous chemicals.
Perform other duties reasonably related to the position and consistent with the incumbent’s 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; follow personnel, safety, infection-control, and compliance policies; and report suspected privacy, security, or compliance concerns through the appropriate process.
Complete SIHD-designated SNF training within the first six months, including abuse and neglect prevention and reporting, resident rights, dementia care, behavioral health, infection prevention, HIPAA, and compliance and ethics; complete initial training, competency validation, and department orientation.