Social Worker

Kin On is seeking a Social Worker working in a skilled nursing facility (SNF) with mainly elders needing short-term and/or long-term care. The primary functions of this position are 1) to coordinate admission process, facilitate transition during short-term rehabilitation stay, and discharge planning; 2) to assist resident's adjustment into a Long-term care facility, maintain their maximum level of health and independence, and work with their family and multi-disciplinary team in caring for these residents.

• Collects required client service utilization and demographic information.
• Performs comprehensive psychosocial assessment of residents.
• Serves as a member of an interdisciplinary team in coordinating admission process, developing individual care plan and discharge planning for residents on Rehabilitation Services.
• Counsels resident and their family on long-term care options and services, bereavement, caregiver stress, and advocate for resident's right.
• Attends regular meeting such as daily stand-up meeting, resident care plan conference, family council meeting, social services team meeting, and psychotropic medication review committee.
• Completes on-going documentation and required evaluation.
• Makes referral and coordinate services such as mental health, home health, home care, respite services and durable medical equipment.
• Works with resident to maximize and preserve their quality of life.
• Works with residents' family, nursing home staffs, other health care professionals (such as MH, therapist, ARNP, PCP) in providing comprehensive care to residents.
• Maintains accurate, up-to-date and complete records of all clients and collateral contacts.
• Ensures services are in compliance with all applicable federal, state and local laws and regulations.
• Performs other duties as required.