Clinical Social Worker: Care Coordination & Discharge

Pioneer Health Care Management Inc; Ashley (MI); On-site; USD 42,000 - 64,000; Full time

Job summary

Pioneer Health Care Management Inc. is seeking a Social Worker in Ashley, MI for a full-time position. You will identify residents’ social, emotional, and psychological needs and develop plans to aid their full potential during their stay. You will educate families on post-acute options and assist with discharge planning.

The role requires coordinating with the IDT, completing required forms, and ensuring high-quality social services documentation and resident rights support.

Responsibilities

• Complete and document Social Work and Psychosocial assessments for residents within 3 days of admission or readmission.
• Ensure 3877/78 forms are completed and accurate upon admission and annually.
• Coordinate care with the interdisciplinary team and conduct Resident Care Conferences as scheduled.
• Complete MDS sections and the appropriate Care Assessments (CAA).
• Develop and update Care Plans including Psychosocial, Discharge Planning, Behavioral, and Cognitive needs.
• Educate residents and families about Advanced Directives and complete related forms within 48 hours of admission.

Education

Licensed Social Worker (LSW)

Job description

Pioneer Health Care Management Inc. is seeking a Social Worker in Ashley, MI for a full-time position. You will identify residents’ social, emotional, and psychological needs and develop plans to aid their full potential during their stay. You will educate families on post-acute options and assist with discharge planning.

The role requires coordinating with the IDT, completing required forms, and ensuring high-quality social services documentation and resident rights support.