Social Worker - Discharge Planning

Elderwood Administrative Services; Scranton (NY); On-site; USD 29,000 - 48,000; Full time

Job summary

Elderwood Administrative Services seeks a Social Worker to join Elderwood at Hamburg in Hamburg, NY. You will advocate for residents and coordinate with families and the interdisciplinary team to ensure smooth transitions and high-quality care.

You will support residents across long-term care, memory care, and subacute rehabilitation, helping with discharge planning, admissions, and resources while upholding dignity and independence.

Qualifications

• Bachelor's degree in Social Work or a related field from an accredited institution.
• At least one year of supervised social work experience in a healthcare setting with individuals.
• Previous casework experience.
• Strong communication, documentation, organization, and interdisciplinary collaboration skills.
• Genuine interest in working with older adults and supporting residents and families through healthcare transitions.
• Valid driver’s license and a driving record that meets company requirements.
• Ability to read, write, speak, and understand English at an intermediate or more advanced level.

Responsibilities

• Manage an assigned social work caseload and serve as a consistent resource for residents and their families.
• Welcome and help orient new residents, supporting their emotional and social adjustment to the community.
• Identify psychosocial, emotional, mental health, and practical needs and coordinate access to appropriate services and resources.
• Participate in the development and review of individualized care plans with the interdisciplinary care team.
• Advocate for residents’ preferences, individuality, independence, dignity, and right to participate in decisions about their care.
• Support residents and families through changes in condition, difficult decisions, transfers, and transitions to another level of care.
• Participate actively in discharge planning and help coordinate safe, appropriate transitions.
• Complete required admission and discharge assessments, including SCREEN documentation when applicable.
• Provide supportive individual or group counseling and connect residents and families with financial, community, or personal resources within the scope of the position.
• Maintain accurate, timely documentation in accordance with facility, departmental, and regulatory requirements.
• Collaborate with nursing, rehabilitation, medical providers, admissions, and other facility departments to address residents’ physical, emotional, and social needs.
• Participate in staff education and in-service programs as requested.

Skills

Communication

Documentation

Organization

Interdisciplinary collaboration

Driver's license

English proficiency

Education

Bachelor's degree in Social Work or related field

Job description

Salary

Up to $35.00 / Hour

Overview

Social Worker – Skilled Nursing

Elderwood at Hamburg | 5775 Maelou Drive, Hamburg, NY 14075

Full Time

Meaningful Social Work - Close to Home in the Southtowns

A transition into skilled nursing - or back home following rehabilitation - can be an uncertain time for residents and their families. They need someone who will listen, advocate for what matters to them, explain what comes next, and bring the right people and resources together.

Elderwood at Hamburg is seeking a Social Worker to join our interdisciplinary team in Hamburg, NY. Conveniently located for professionals throughout the Southtowns, our 166-bed community provides skilled nursing, long-term care, subacute rehabilitation, and memory care.

This is a visible and meaningful position with the opportunity to support residents across different stages of care—from individuals recovering after an illness, injury, or surgery to those making Elderwood their long-term home.

Your Impact at Elderwood at Hamburg

As a Social Worker, you will serve as an advocate, resource, and steady point of contact for residents and their families. You will help people adjust to a new environment, work through complex decisions, overcome barriers, and prepare for safe and appropriate care transitions.

You will also collaborate closely with nursing, rehabilitation, medical providers, admissions, and other facility departments to keep each resident’s needs, preferences, independence, and dignity central to the care plan.

What Makes This Opportunity Different

At Elderwood at Hamburg, social work touches every part of the resident experience. You will support individuals receiving long-term nursing care, memory care, and short-term rehabilitation, including cardiac, orthopedic, and post-surgical recovery.

The variety of resident needs makes this an excellent opportunity for a social worker who values interdisciplinary practice, thoughtful discharge planning, resident advocacy, and the ability to make a practical difference for families.

Bring Your Experience Back to the Southtowns

If you are a social worker in Hamburg, Orchard Park, West Seneca, Lackawanna, Blasdell, Lake View, Derby, Eden, or the surrounding Southtowns, consider an opportunity where your work will have a direct and visible impact.

Join Elderwood at Hamburg and help residents and families move forward with greater clarity, dignity, and support.

Responsibilities

What You’ll Be Responsible For

• Manage an assigned social work caseload and serve as a consistent resource for residents and their families.

• Welcome and help orient new residents, supporting their emotional and social adjustment to the community.

• Identify psychosocial, emotional, mental health, and practical needs and coordinate access to appropriate services and resources.

• Participate in the development and review of individualized care plans with the interdisciplinary care team.

• Advocate for residents’ preferences, individuality, independence, dignity, and right to participate in decisions about their care.

• Support residents and families through changes in condition, difficult decisions, transfers, and transitions to another level of care.

• Participate actively in discharge planning and help coordinate safe, appropriate transitions.

• Complete required admission and discharge assessments, including SCREEN documentation when applicable.

• Provide supportive individual or group counseling and connect residents and families with financial, community, or personal resources within the scope of the position.

• Maintain accurate, timely documentation in accordance with facility, departmental, and regulatory requirements.

• Collaborate with nursing, rehabilitation, medical providers, admissions, and other facility departments to address residents’ physical, emotional, and social needs.

• Participate in staff education and in-service programs as requested.

From

Up to

Qualifications

Required Qualifications

• Bachelor’s degree in Social Work or a related human services field from an accredited institution. Related fields may include psychology, sociology, gerontology, rehabilitation counseling, special education, or another qualifying discipline.

• At least one year of supervised social work experience in a healthcare setting working directly with individuals.

• Previous casework experience.

• Strong communication, documentation, organization, and interdisciplinary collaboration skills.

• Genuine interest in working with older adults and supporting residents and families through healthcare transitions.

• Valid driver’s license and a driving record that meets company requirements.

• Ability to read, write, speak, and understand English at an intermediate or more advanced level to communicate safely and effectively with residents, families, visitors, coworkers, and supervisors.

Preferred Experience

• Social work experience in skilled nursing, long-term care, rehabilitation, geriatrics, or a related healthcare setting.

• Experience supporting admissions, discharge planning, transfers, or transitions of care.

• This position requires regular interaction with residents, coworkers, visitors, and/or supervisors. In order to ensure a safe work environment for residents, coworkers, visitors, and/or supervisors of the Company, and to permit unfettered communication between the employee and those residents, coworkers, visitors, and supervisors, this position requires that the employee be able to read, write, speak, and understand the English language at an intermediate or more advanced level.

EOE Statement

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.