Social Worker Skilled Nursing (Per Diem)

Cape Cod Healthcare•Falmouth, MA

11d•Onsite

About The Position

This position is for a Social Worker in a Skilled Nursing facility, working on a per diem basis. The role involves comprehensive patient/resident assessments, developing and implementing care plans in collaboration with other professionals, and coordinating discharge plans. The Social Worker will also refer patients/residents to community resources, complete necessary documentation like the MDS, and assist with advanced care planning. Key responsibilities include facilitating communication with patients and families, ensuring successful transitions to the community, educating staff and residents on their rights, and advocating for patients/residents. The role requires maintaining confidentiality of resident information and adhering to all regulations. The Social Worker is expected to provide service excellence in line with the organization's CARES values: compassion, accountability, respect, excellence, and service.

Requirements

Bachelor's degree in social work or a related field from an accredited college or university.
Must be licensed in Massachusetts.
Must have, as a minimum, one (1) year supervised social work experience in a health care setting working directly with the elderly or disabled.
Must be able to read, write, speak, and understand the English language.
Knowledge of community resources.
Must possess the ability to make independent decisions when circumstances warrant such action.
Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served.
Must be a supportive team member, contribute to and be an example of team work and team concept.
Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.
Must have patience, tact, cheerful disposition and enthusiasm, as well as be willing to handle residents based on whatever maturity level in which they are currently functioning.
Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing social services.

Nice To Haves

A member in good standing in the National Association of Social Workers and Academy of Certified Social Workers, Inc., preferred.

Responsibilities

Performs each patient’s/resident’s initial comprehensive assessment to determine and best meet the goals of this patient/resident.
Works in collaboration with other professional disciplines to develop a patient/resident directed plan of care.
Develop discharge plans as determined by patient/resident and their Responsible Party.
Refers patients/residents, as necessary, to community resources and other organizations to best meet these discharge plans.
Completes Social Service section of the MDS (Minimum Data Set Assessment) within the CMS mandated time frame.
Assists patient/resident with Advanced Care planning.
Involves patients and families in the interdisciplinary care process by coordinating and participating in care/discharge planning and initiating referrals for appropriate home care services if necessary prior to the resident’s return to the community.
Facilitates communication with post-discharge residents to insure a successful discharge transition to community.
Ensures that social service progress notes are informative and descriptive of the services provided and are completed in a timely manner as directed by Department of Public Health and CMS regulations.
Participates in and attends various committees of the facility as required.
Assists in educating residents and staff in Resident’s rights as mandated by Executive Office of Health & Human Services.
Advocates on behalf of all patients/residents, as needed.
Communicates weekly with Ombudsman Representative of Elder Services, as needed.
Maintains the confidentiality of all resident care information including protected health information. Reports known or suspected incidents of unauthorized disclosure of such information; and adheres to Resident’s rights.
Performs other work related duties as requested.
Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects JML’s commitment to CARES: compassion, accountability, respect, excellence and service.