Resident Care & Transitions Leader

The Orchards; Chester (Delaware County); Presencial; USD 65.000 - 85.000; Jornada completa

Descripción de la vacante

The Orchards is seeking a Social Services Coordinator to manage resident social services from admission through discharge, advocate for residents, and coordinate care transitions with the interdisciplinary team. The role emphasizes addressing psychosocial needs, communicating with families, and ensuring access to resources.

Responsibilities include conducting psychosocial assessments, updating care plans, and educating residents and families about available services and community resources.

Formación

• Associate's or Bachelor's degree in Social Work, Human Services, or a related field is required.
• Current Social Work license preferred, or eligibility for licensure where applicable.
• Minimum of five (5) years of experience in social services, long-term care, skilled nursing, or a related healthcare setting preferred.
• Experience with resident assessments, discharge planning, care planning, and MDS processes preferred.
• Knowledge of state and federal regulations governing long-term care facilities.

Responsabilidades

• Coordinate resident admissions, including receiving referrals, completing psychosocial assessments, and facilitating a smooth transition into the facility.
• Coordinate resident discharges by arranging referrals, transportation, physician orders, family meetings, and community resources to ensure safe transitions.
• Review and prioritize Minimum Data Set (MDS) assessments in collaboration with the interdisciplinary team.
• Review resident documentation related to psychosocial needs, behaviors, mood, and emotional well-being.
• Meet regularly with residents and family members to provide counseling, education, support, advocacy, and problem resolution.
• Advocate for resident rights while maintaining confidentiality and promoting resident-centered care.
• Collaborate with nursing, therapy, dietary, activities, and other departments to ensure coordinated care planning.
• Assist with developing, implementing, and updating individualized resident care plans.
• Participate in care conferences and communicate resident goals and discharge planning needs.Complete required documentation, reports, and regulatory records accurately and timely.
• Maintain knowledge of Medicare, Medicaid, community resources, and financial assistance programs available to residents.
• Educate residents and families regarding available services and community resources.
• Promote effective communication between residents, families, physicians, and the interdisciplinary team.
• Participate in mandatory meetings, in-services, and continuing education.
• Perform other duties as assigned.

Conocimientos

Communication

Counseling

Interpersonal skills

MDS processes

EHR proficiency

Educación

Associate's or Bachelor's degree in Social Work, Human Services, or related field

Herramientas

EHR software

Microsoft Office

Descripción del empleo

The Orchards is seeking a Social Services Coordinator to manage resident social services from admission through discharge, advocate for residents, and coordinate care transitions with the interdisciplinary team. The role emphasizes addressing psychosocial needs, communicating with families, and ensuring access to resources.

Responsibilities include conducting psychosocial assessments, updating care plans, and educating residents and families about available services and community resources.