Resident-Centered Social Worker & Care Navigator

Hill Valley Healthcare; Maplewood Estates (TN); On-site; USD 52,000 - 68,000; Full time

Benefits offered by this job

Competitive pay

Paperless onboarding

Comprehensive benefits (health, dental

retirement plan)

Flexible scheduling

Paid time off

Holiday pay

Tuition reimbursement & CEU support

Annual performance reviews

Job summary

WyndRidge Health and Rehabilitation Center in Crossville, TN seeks a dedicated Social Worker to support residents’ psychosocial well-being, coordinate care planning, and advocate for timely, person-centered services.

You will collaborate with residents, families, physicians, and the interdisciplinary team to ensure compliance with CMS/state regulations while promoting dignity, independence, and quality of life throughout care transitions.

Qualifications

• Bachelor's Degree in Social Work (BSW) or related field is required.
• Current Social Work license as required by state regulations.
• Experience in skilled nursing, long-term care, rehabilitation, or healthcare preferred.
• Knowledge of CMS regulations, discharge planning, and long-term care standards.
• CPR certification preferred.

Responsibilities

• Conduct psychosocial assessments upon admission and as needed throughout the resident's stay.
• Develop, implement, and update individualized care plans in collaboration with the interdisciplinary team.
• Provide emotional support, counseling, and crisis intervention to residents and families.
• Assist residents and families in understanding diagnoses, treatment plans, and available community resources.
• Coordinate discharge planning to ensure safe and successful transitions to home, assisted living, or other levels of care.
• Arrange home health services, durable medical equipment, transportation, and other post-discharge resources as needed.
• Serve as a liaison between residents, families, physicians, and facility staff to promote effective communication.
• Advocate for resident rights and ensure residents maintain dignity, independence, and quality of life.
• Assist with advance directives, healthcare decision-making, and end-of-life planning when appropriate.
• Participate in admissions, care conferences, family meetings, and discharge planning meetings.
• Address resident concerns, grievances, and complaints promptly while working toward appropriate resolution.
• Monitor residents for psychosocial changes and communicate concerns to the interdisciplinary team.
• Maintain accurate, timely, and complete documentation in accordance with facility policies and regulatory requirements.
• Ensure compliance with CMS, state, and federal regulations related to social services.
• Participate in Quality Assurance and Performance Improvement (QAPI) initiatives.
• Assist with resident adjustment, behavior management, and interventions that enhance quality of life.
• Build relationships with community agencies and referral sources to support resident needs.
• Perform other duties as assigned.

Education

Bachelor's Degree in Social Work (BSW) or related field

Job description

WyndRidge Health and Rehabilitation Center in Crossville, TN seeks a dedicated Social Worker to support residents’ psychosocial well-being, coordinate care planning, and advocate for timely, person-centered services.

You will collaborate with residents, families, physicians, and the interdisciplinary team to ensure compliance with CMS/state regulations while promoting dignity, independence, and quality of life throughout care transitions.