Social Services and Discharge Planning Assistant

Job Description

Position: Social Services & Discharge Planning Assistant - Skilled Nursing Facility
Job Type: Full-time Exempt

The Social Services & Discharge Planning Assistant will support our growing Social Services team ensuring that the social, psychological, and physical needs of all residents in the facility are being met. This position is responsible for assisting in the coordination of all aspects of the patient’s safe discharge from the facility. The ideal candidate for the position is passionate about helping people and is skilled in conveying compassion and empathy.

Overview:

Vierra Falls Church Health & Rehabilitation is a family-owned and operated community that provides a truly unique health & rehabilitation experience. We have a close-knit staff that will do anything to create the best community and experience for our residents. This is a very exciting time to be at Vierra Falls Church as we recently completed a major renovation to our beautiful community.

We offer competitive pay commensurate with experience, a comprehensive benefits package and a positive work environment with a team that is committed to growth and providing excellent customer service.

Benefits:

• 7 Paid Holidays
• Generous PTO
• Medical, Dental and Vision
• Company Paid Life & AD&D Insurance
• Voluntary Life & AD&D Insurance
• 401(k) immediate enrollment with match
• Tuition Reimbursement
• Referral Bonus Program

Required Qualifications

• A minimum of a bachelor’s degree in social work or another human services field to include, but not limited to, sociology, gerontology, special education, rehabilitation counseling, or psychology.
• One year of supervised social work experience in a health care setting working directly with individuals.

Major Duties and Responsibilities

• Assist in overseeing the development, implementation, supervision, and ongoing evaluation of the Social Services Department designed to meet and assist residents in attaining or maintaining their highest practicable well-being. This includes identifying the need for medically related social services and ensuring that these services are provided in accordance with State and Federal regulations.
• Facilitate residents’ safe transition back into the community based on the resident/representative’s wishes, safety, and clinical recommendations.
• Collaborate with the team to identify clinical discharge planning needs and arrangement of community-based services and follow-up care within the community.
• Research, identify, and arrange external services for residents such as Chaplaincy, Advocates, Responsible Parties, and optimal care environments.
• Assist with conversations surrounding resources such as Medicaid, assisted living, or other community resources when applicable. Conduct Universal Assessment Instruments (UAI) when appropriate and necessary for the Medicaid process.
• Direct timely and efficient five-day discharge planning meetings for all newly admitted residents through completion of assessments. Upon admission, may also conduct other assessments such as cognitive assessments, depression screenings, suicide risk screenings, etc.
• Assist with coding in the Minimum Data Set (MDS) for assigned sections.
• Facilitate effective bed management by strategic evaluation and internal arrangement to maximize availability of transitional and extended care services.
• Meet with and assist residents with social issues such as conflict resolution, problem-solving, and care coordination.
• Conduct customer satisfaction surveys, assist in documenting, tracking, and following up on any patient grievances, and be an advocate in promoting excellent customer service to residents and visitors.
• Complete the social services component of the comprehensive assessment for assigned residents. Contribute to and/or direct/ delegate contribution of social services goals and approaches to the comprehensive care plan. These goals and interventions will be individualized to match the skills, abilities, and interests/preferences of each resident in compliance with Federal and State regulations, to include identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident.
• Assist with completion of preadmission services for inbound residents, to include participation in interdisciplinary evaluation of residents needs for institutional care and completion of the PASARR Level 1.
• Interpret and report the social, psychological, and emotional needs of the resident/responsible party to the medical staff, attending physician, and other resident care team members.
• Accurately and completely document social service actions and interactions in each resident’s medical record, and ensure that legal, ethical, and professional standards of social work practice and being upheld in written recordings.
• Engage in Advance Care Planning for assigned residents upon admission, and make sure that any Advance Directives are reviewed with the resident/resident representative on a regular basis. Assist with end-of-life planning as needed and coordinate palliative or hospice services.
• Assist the Social Services Director in ensuring that staff members are knowledgeable about Resident’s Rights and encourage staff to maintain and enhance each resident’s dignity in recognition of each resident’s individuality.
• Advocate for residents and assist them in assertion of their rights within the facility. When there is an allegation of suspected abuse, neglect or exploitation, The Social Services and Discharge Planning Assistant will report to the Social Services and Discharge Planning Director and/or Administrator and assist with reporting to the appropriate State agency, as well as completion of a thorough investigation as assigned.
• Ensure that residents who display mental illness, or psychosocial difficulties such as coping with grief and loss, have access to appropriate treatment and resources.
• In the absence of the Social Services and Discharge Planning Director, assist in directing the Social Services Department.
• There may be additional duties as assigned by the Director of Social Services and Discharge Planning

Vierra Falls Church provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or genetics. In addition to federal law requirements, Vierra Falls Church. complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities.