Social Worker

Optalis•Sterling Heights, MI

7d•Onsite

About The Position

The Social Worker is responsible for supporting the psychosocial, emotional, and discharge planning needs of residents in a skilled nursing facility. This position serves as an advocate for residents and families while coordinating 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.

Requirements

Bachelor’s degree in Social Work (BSW) required
Current state Social Work licensure or certification preferred or required based 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.
Proficient 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) preferred.
Minimum of one (1) year experience in healthcare, skilled nursing, long-term care, rehabilitation, or hospital setting preferred.

Responsibilities

Complete psychosocial assessments for residents upon admission, quarterly, annually, and with 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 resident rights, dignity, privacy, and self-determination.
Participate in resident care conferences and interdisciplinary team meetings.
Monitor residents 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 processes.
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 alternate levels of care.
Ensure discharge documentation and resident/family education are completed timely and accurately.
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 on resident rights, facility policies, and available services.
Promote resident and family satisfaction through effective communication and support.
Maintain accurate, timely, and compliant documentation in the medical record.
Ensure compliance with federal, state, local, and facility regulations, including CMS requirements.
Participate in quality assurance and performance improvement activities.
Assist during 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 effectively 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.