Licensed Social Worker →

Optalis Healthcare; Muskegon (MI); On-site; USD 52,000 - 76,000; Full time

Job summary

Optalis Healthcare is seeking a dedicated Social Worker to support psychosocial, emotional, and discharge planning needs for residents in a skilled nursing facility. You will advocate for residents and families while coordinating services to promote rights, dignity, and well-being, collaborating with an interdisciplinary team throughout the stay.

You will conduct assessments, develop care plans, provide counseling, and assist with transitions to home or other levels of care, ensuring compliant

Qualifications

• BSW required; MSW preferred.
• Current state social work licensure or certification per state regulations.
• Minimum 1 year experience in healthcare, skilled nursing, long-term care or hospital setting.
• Knowledge of CMS regulations, discharge planning processes, and resident rights.
• Strong communication, organizational and interpersonal skills.
• Ability to work independently and collaboratively within an interdisciplinary team.
• Ability to manage multiple priorities in a fast-paced environment.
• Proficient in electronic medical records and basic computer applications.

Responsibilities

• Complete psychosocial assessments at admission, quarterly, annually, and with significant changes.
• Develop, implement, and update individualized social service care plans.
• Provide emotional support, counseling, and crisis intervention to residents and families.
• Assist residents and families 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.
• Coordinate with hospitals, physicians, home health agencies, hospice providers, dialysis centers, transportation providers, and community agencies.
• Ensure discharge documentation and resident/family education are completed timely and accurately.
• Assist during end-of-life planning and advance directives when appropriate.
• Maintain confidentiality of resident information in accordance with HIPAA regulations.
• Maintain documentation per CMS and facility requirements.

Skills

Communication

Organizational skills

Interpersonal skills

Team collaboration

Time management

Critical thinking

Problem-solving

EMR proficiency

Education

Bachelor's degree in Social Work (BSW)

Master's degree in Social Work (MSW)

Tools

Electronic Medical Records

Basic computer applications

Job description

The Social Worker is responsible for supporting the psychosocial, emotional, and discharge planning needs of residents in a skilled nursing facility. This position serves as an advocate for residents and families while coordinating services that promote resident rights, quality of life, dignity, and emotional well-being. The Social Worker collaborates with the interdisciplinary team to ensure residents receive appropriate support, resources, and care planning throughout their stay.

Essential Duties and Responsibilities

Resident Care & Support

• Complete psychosocial assessments for residents upon admission, quarterly, annually, and with significant changes.
• Develop, implement, and update individualized social service care plans.
• Provide emotional support, counseling, and crisis intervention to residents and families.
• Assist residents and families 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 residents for signs of abuse, neglect, exploitation, depression, anxiety, or psychosocial decline and report concerns according to facility policy.
• Assist with advance directives, guardianship concerns, and end-of-life planning when appropriate.
• Collaborate with hospitals, physicians, home health agencies, hospice providers, dialysis centers, transportation providers, and community agencies.
• Arrange referrals and resources for residents transitioning to home or alternate levels of care.
• Ensure discharge documentation and resident/family education are completed timely and accurately.
• Participate in insurance-related discharge planning discussions as needed.

Family & Resident Relations

• Maintain regular communication with residents and responsible parties.
• Address resident and family concerns promptly and professionally.
• Assist with conflict resolution and grievance management.
• Educate residents and families on resident rights, facility policies, and available services.
• Promote resident and family satisfaction through effective communication and support.

Regulatory & Documentation Responsibilities

• Maintain accurate, timely, and compliant documentation in the medical record.
• Ensure compliance with federal, state, local, and facility regulations, including CMS requirements.
• Participate in quality assurance and performance improvement activities.
• Assist during surveys and audits by providing requested documentation and information.
• Maintain confidentiality of resident information in accordance with HIPAA regulations.

Administrative & Team Responsibilities

• Participate in facility committees and meetings as assigned.
• Collaborate effectively with nursing, therapy, dietary, activities, and administration departments.
• Support facility initiatives related to resident-centered care and quality outcomes.
• Maintain current knowledge of community resources and long-term care regulations.
• Perform other duties as assigned.

Qualifications

• Bachelor’s degree in Social Work (BSW) required; Master’s degree in Social Work (MSW) preferred.
• Current state Social Work licensure or certification preferred or required based on state regulations.
• Minimum of one (1) year experience in healthcare, skilled nursing, long-term care, rehabilitation, or hospital setting preferred.
• Knowledge of CMS regulations, discharge planning processes, and resident rights.
• Strong communication, organizational, and interpersonal skills.
• Ability to work independently and collaboratively within an interdisciplinary team.
• Ability to manage multiple priorities in a fast-paced environment.
• Proficient in electronic medical records and basic computer applications.

Physical Requirements

• Ability to sit, stand, walk, bend, and move throughout the facility for extended periods.
• Ability to lift, push, or pull up to 25 pounds occasionally.
• Ability to communicate effectively with residents, families, staff, and external providers.
• Skilled nursing and rehabilitation facility environment.
• Frequent interaction with residents, family members, healthcare professionals, and visitors.

Schedule

• Full-time position.
• Weekday schedule with occasional evenings, weekends, or holidays as needed to support resident care and facility operations.
• Compassion and empathy
• Resident advocacy
• Crisis intervention
• Communication and conflict resolution
• Time management and organization
• Critical thinking and problem-solving
• Team collaboration
• Professionalism and confidentiality
• Competitive compensation
• Health, dental, and vision insurance
• Paid time off and holiday pay
• Retirement plan options
• Continuing education opportunities
• Supportive team environment