Discharge & Care Coordination Social Worker (LSW/LICSW)

Pinnacle Health & Rehab; Braintree (MA); On-site; USD 65,000 - 90,000; Full time

Job summary

Pinnacle Health & Rehab in Massachusetts is seeking a dedicated Social Worker to collaborate with the Director of Social Services to ensure timely assessments and meaningful care plans for residents. You will coordinate with discharge planners, evaluate patient needs, and support families through aging, illness, coping, and loss.

The role emphasizes leading discharge planning, coordinating with PT/OT, and developing comprehensive care plans, with a focus on ensuring smooth transitions back to

Qualifications

• BA or Master’s degree in social work.
• Valid and current LCSW license in good standing.
• Clinical social work experience with residents with disabilities (TBI, Behavioral Health) preferred.
• Excellent listening and communication skills.
• Ability to make psychosocial assessments and develop and implement care plans.
• Ability to provide after-hours service as needed.
• Prior experience in a Social Service department in a Skilled Nursing Facility for 2+ years is a plus.

Responsibilities

• Provide residents and families with education and support regarding aging, illness, coping and loss.
• Demonstrate an understanding of advanced directives, healthcare proxies, guardianship requirements and the like.
• Lead discharge planning and coordination of services needed for a successful transition back to the appropriate community setting.
• Evaluate patients based on their needs, limitations and desires.
• Address patient concerns and goals while maintaining constant communication with the patient as well as a case manager.
• Build rapport with patients and their families.
• Coordinate care with PT and OT departments.
• Develop care plans for patients.

Skills

Active listening

Communication skills

Psychosocial assessment

Care planning

Discharge planning coordination

After-hours availability

SNF experience

Education

BA or MSW

LCSW license

Job description

Pinnacle Health & Rehab in Massachusetts is seeking a dedicated Social Worker to collaborate with the Director of Social Services to ensure timely assessments and meaningful care plans for residents. You will coordinate with discharge planners, evaluate patient needs, and support families through aging, illness, coping, and loss.

The role emphasizes leading discharge planning, coordinating with PT/OT, and developing comprehensive care plans, with a focus on ensuring smooth transitions back to