Skilled Nursing Social Worker - Discharge & Care Planning

Cape Cod Healthcare; Falmouth (MA); On-site; USD 48,216 - 66,124; Part time

Job summary

JML Care Center in Massachusetts - Falmouth is seeking a licensed Social Worker to provide psychosocial support to SNF residents. You will perform initial assessments, develop care plans with a multidisciplinary team, and coordinate discharge planning with families and community resources.

The role includes advanced care planning, collaboration with various committees, and maintaining compliant documentation per DPH and CMS rules. 32 hours weekly, with occasional weekends and holidays.

Qualifications

• Must be licensed in Massachusetts.
• Must have, as a minimum, one (1) year supervised social work experience in a health care setting working directly with the elderly or disabled.
• Must be able to read, write, speak, and understand the English language.
• Knowledge of community resources.
• Must possess the ability to make independent decisions when circumstances warrant such action.

Responsibilities

• Performs each patient’s/resident’s initial comprehensive assessment to determine and best meet the goals of this patient/resident.
• Works in collaboration with other professional disciplines to develop a patient/resident directed plan of care.
• Develop discharge plans as determined by patient/resident and their Responsible Party.
• Refers patients/residents, as necessary, to community resources and other organizations to best meet these discharge plans.
• Will complete Social Service section of the MDS (Minimum Data Set Assessment) within the CMS mandated time frame
• Will assist patient/resident with Advanced Care planning.
• Involves patients and families in the interdisciplinary care process by coordinating and participating in care/discharge planning and initiating referrals for appropriate home care services if necessary prior to the resident’s return to the community.
• Will facilitate communication with post-discharge residents to insure a successful discharge transition to community.
• Must ensure that social service progress notes are informative and descriptive of the services provided and are completed in a timely manner as directed by Department of Public Health and CMS regulations.
• Will participate in and attend various committees of the facility as required.
• Will assist in educating residents and staff in Resident’s rights as mandated by Executive Office of Health & Human Services.
• Will advocate on behalf of all patients/residents, as needed.
• Will communicate weekly with Ombudsman Representative of Elder Services, as needed.

Education

Bachelor's degree in social work or a related field

Job description

JML Care Center in Massachusetts - Falmouth is seeking a licensed Social Worker to provide psychosocial support to SNF residents. You will perform initial assessments, develop care plans with a multidisciplinary team, and coordinate discharge planning with families and community resources.

The role includes advanced care planning, collaboration with various committees, and maintaining compliant documentation per DPH and CMS rules. 32 hours weekly, with occasional weekends and holidays.