Licensed Social Worker SNF

Job Description: Social Worker

Long-Term Care Skilled Nursing Facility (CMS & HHS Compliant)

Position Summary

The Social Worker in a long-term care skilled nursing facility plays a critical role in supporting residents and their families by addressing social, emotional, and psychosocial needs. This position ensures compliance with Centers for Medicare & Medicaid Services (CMS) and U.S. Department of Health & Human Services (HHS) guidelines, helping residents achieve the highest practicable level of well-being.

Essential Duties and Responsibilities

• Assessment and Care Planning
• Conduct comprehensive psychosocial assessments upon admission, quarterly, annually, and with significant changes in resident status.
• Participate in interdisciplinary care planning meetings and contribute to the development and updating of individualized care plans.
• Identify and address residents’ social, emotional, and mental health needs, ensuring documentation is accurate and CMS-compliant.

Resident Advocacy and Support

Serve as an advocate for residents’ rights, dignity, and preferences, ensuring their voices are heard in all matters affecting their care.

Educate residents and families about facility policies, advance directives, and community resources.

Assist residents and families with adjustment to the facility, including orientation, counseling, and ongoing support.

Discharge Planning and Transitions of Care

Coordinate discharge planning, including assessments of post-discharge needs, referrals to community services, and arrangement of home care or alternative placements.

Collaborate with the interdisciplinary team, residents, and families to ensure safe and effective transitions of care.

Psychosocial Interventions

Provide individual and group counseling to address grief, loss, depression, anxiety, and behavioral health needs.

Develop and implement interventions to support residents’ psychosocial well-being and prevent or address adjustment difficulties.

Respond to and resolve resident grievances, complaints, and allegations of abuse, neglect, or exploitation in accordance with facility policy and federal guidelines.

Compliance and Documentation

Maintain accurate, timely, and CMS-compliant documentation in resident medical records, including assessments, interventions, care plans, progress notes, and discharge summaries.

Adhere to all applicable CMS, HHS, state, and facility regulations and policies regarding social work services.

Participate in Quality Assurance and Performance Improvement (QAPI) activities as requested.

Family and Community Relations

Facilitate communication between residents, families, and the care team.

Organize and participate in care conferences, family meetings, and support groups.

Connect residents and families to financial, legal, and community resources as needed.

Education and Training

Provide in-service training to facility staff on topics such as residents’ rights, abuse prevention, and psychosocial care.

Stay current with CMS and HHS guidelines, best practices, and state regulations relevant to long-term care social work.

Other Duties

Participate in emergency preparedness and response activities.

Perform other duties as assigned by the Administrator.

Qualifications

• Bachelor’s or Master’s Degree in Social Work (BSW or MSW) from an accredited program.
• Current state licensure or certification as required.
• Experience in long-term care or healthcare setting preferred.
• Knowledge of CMS and HHS regulations for skilled nursing facilities.
• Strong communication, organizational, and problem-solving skills.
• Ability to work collaboratively in a multidisciplinary team environment.

Physical and Working Conditions

• Work is performed in a skilled nursing facility environment.
• May require occasional lifting, standing, or walking.
• May involve exposure to residents with infectious diseases or behavioral challenges.

Work Location: In person