Social Worker - Discharge Planning

Elderwood•Hamburg, NY

3d•$35•Onsite

About The Position

Elderwood at Hamburg is seeking a Social Worker to support residents and families at its 166-bed skilled nursing community in Hamburg, New York. The community provides skilled nursing, long-term care, subacute rehabilitation, and memory care, including cardiac, orthopedic, and post-surgical recovery. The role supports residents at different stages of care and helps them adjust to the community, navigate complex decisions, and prepare for safe and appropriate transitions. The Social Worker serves as an advocate, resource, and consistent point of contact for residents and families. Working with an interdisciplinary team—including nursing, rehabilitation, medical providers, admissions, and other facility departments—the role helps keep residents’ needs, preferences, independence, and dignity central to their care. The position also involves discharge planning, assessments, counseling, resource coordination, and timely documentation.

Requirements

Bachelor’s degree in Social Work or a related human services field from an accredited institution; qualifying fields may include psychology, sociology, gerontology, rehabilitation counseling, or special education.
At least one year of supervised social work experience in a healthcare setting working directly with individuals.
Previous casework experience.
Strong communication, documentation, organization, and interdisciplinary collaboration skills.
Genuine interest in working with older adults and supporting residents and families through healthcare transitions.
Valid driver’s license and a driving record that meets company requirements.
Ability to read, write, speak, and understand English at an intermediate or more advanced level.

Nice To Haves

Social work experience in skilled nursing, long-term care, rehabilitation, geriatrics, or a related healthcare setting.
Experience supporting admissions, discharge planning, transfers, or transitions of care.

Responsibilities

Manage an assigned social work caseload and serve as a consistent resource for residents and their families.
Welcome and orient new residents, supporting their emotional and social adjustment to the community.
Identify psychosocial, emotional, mental health, and practical needs and coordinate access to appropriate services and resources.
Participate in developing and reviewing individualized care plans with the interdisciplinary care team.
Advocate for residents’ preferences, individuality, independence, dignity, and right to participate in care decisions.
Support residents and families through changes in condition, difficult decisions, transfers, and transitions to another level of care.
Participate in discharge planning and help coordinate safe, appropriate transitions.
Complete required admission and discharge assessments, including SCREEN documentation when applicable.
Provide supportive individual or group counseling and connect residents and families with financial, community, or personal resources within the scope of the position.
Maintain accurate and timely documentation in accordance with facility, departmental, and regulatory requirements.
Collaborate with nursing, rehabilitation, medical providers, admissions, and other facility departments to address residents’ physical, emotional, and social needs.
Participate in staff education and in-service programs as requested.