Geriatric Social Worker & Care Navigator

Optalis Healthcare (Health & Rehabilitation Centers); Troy (MI); On-site; USD 60,000 - 75,000; Full time

Benefits offered by this job

Competitive compensation

Health, dental, and vision insurance

Paid time off and holidays

Retirement plan options

Continuing education opportunities

Supportive team environment

Job summary

Optalis Healthcare (Health & Rehabilitation Centers) is seeking a Social Worker to support residents in a skilled nursing facility. The role includes psychosocial assessments, care planning, emotional support, and discharge planning while advocating for resident rights and well-being.

You will collaborate with an interdisciplinary team to coordinate resources, document care, and educate residents and families about options and rights. This is a full-time, on-site position in Michigan.

Qualifications

• BSW required; MSW preferred.
• Current state social work licensure or certification preferred or required by state regulations.
• Minimum of one year of healthcare, skilled nursing, long-term care, rehabilitation, or hospital experience preferred.
• Knowledge of CMS regulations, discharge planning processes, and resident rights.
• Proficiency with electronic medical records and basic computer applications.

Responsibilities

• Complete psychosocial assessments on admission, quarterly, annually, and with significant changes.
• Develop and update individualized social service care plans.
• Provide emotional support, counseling, and crisis intervention to residents and families.
• Assist with adjustment to illness, disability, placement, and long-term care living.
• Identify psychosocial concerns and coordinate appropriate interventions.
• Advocate for resident rights, dignity, privacy, and self-determination.
• Participate in resident care conferences and interdisciplinary team meetings.
• Monitor for abuse, neglect, depression, anxiety, or psychosocial decline and report concerns.
• Assist with advance directives, guardianship, and end-of-life planning when appropriate.
• Collaborate with hospitals, home health agencies, hospice, and community resources.
• Arrange referrals and resources for transitions to home or alternate level of care.
• Ensure discharge documentation and resident/family education are completed timely.

Skills

Communication skills

Organizational skills

Interpersonal skills

Independent yet collaborative

Education

Bachelor of Social Work (BSW)

Master of Social Work (MSW) preferred

Job description

Optalis Healthcare (Health & Rehabilitation Centers) is seeking a Social Worker to support residents in a skilled nursing facility. The role includes psychosocial assessments, care planning, emotional support, and discharge planning while advocating for resident rights and well-being.

You will collaborate with an interdisciplinary team to coordinate resources, document care, and educate residents and families about options and rights. This is a full-time, on-site position in Michigan.