Long-Term Care Social Worker: Discharge Planning & Support

Tri Care LLC; New York (NY); On-site; USD 55,000 - 85,000; Full time

Job summary

Tri Care LLC is seeking a compassionate Social Worker to join our interdisciplinary care team in a New York State-licensed nursing home. You will address residents’ psychosocial needs, support adjustment to long-term care, and manage MDS responsibilities and discharge planning.

You will assist residents and families with benefits, coordinate services, and collaborate with hospitals, providers, and staff to ensure safe transitions and resource access for dignified, patient-centered care.

Qualifications

• Associate degree from an accredited institution.
• Experience in long-term care or discharge planning is required.
• Familiarity with the MDS process, care planning, and psychosocial documentation is preferred.
• Experience coordinating benefits, entitlement programs, and community resources is preferred.
• Experience in a nursing home, skilled nursing facility, or healthcare setting is preferred.
• Strong communication, assessment, organizational, and documentation skills.
• Ability to work effectively with elderly residents, families, interdisciplinary team members, community agencies, and benefit program representatives.
• Multilingual candidates are strongly encouraged to apply; multilingual ability is a plus.

Responsibilities

• Complete initial, quarterly, annual, and significant-change psychosocial assessments.
• Complete assigned MDS sections, assessments, care area assessments, and supporting documentation accurately and within required timeframes.
• Participate in the MDS process and interdisciplinary care planning, including resident care conferences and development of resident-centered care plans.
• Address applicable MDS discharge-planning requirements, including Section Q, referrals, documentation, and follow-up, as appropriate.
• Provide counseling and psychosocial support to residents and families.
• Assist residents with adjustment to institutional living, illness, disability, and end-of-life issues.
• Coordinate discharge planning and safe transitions to the community or an alternate level of care.
• Work with residents, families, hospitals, community providers, and facility staff to identify services, equipment, housing, transportation, and other resources needed for a safe discharge.
• Assist residents and families with the coordination of benefits and entitlement programs, including Medicaid, Medicare, Social Security, Supplemental Security Income, veterans' benefits, and other available programs and community resources.
• Serve as a liaison among residents, families, facility staff, hospitals, insurance providers, government agencies, and community organizations.
• Participate in interdisciplinary care planning, resident care conferences, and Quality Assurance and Performance Improvement (QAPI) activities.
• Investigate, document, and assist in resolving resident and family concerns and grievances.
• Assist with advance directives, health care proxies, MOLST forms, guardianship matters, and referrals to community resources.
• Maintain timely and accurate documentation in the electronic medical record.
• Participate in surveys, audits, and reviews as needed.
• Maintain confidentiality in accordance with HIPAA and New York State privacy requirements.

Skills

Interpersonal communication

Assessment skills

Documentation

Care planning

Discharge planning

Multilingual

Education

Associate degree

Job description

Tri Care LLC is seeking a compassionate Social Worker to join our interdisciplinary care team in a New York State-licensed nursing home. You will address residents’ psychosocial needs, support adjustment to long-term care, and manage MDS responsibilities and discharge planning.

You will assist residents and families with benefits, coordinate services, and collaborate with hospitals, providers, and staff to ensure safe transitions and resource access for dignified, patient-centered care.