Social Worker in LTC Skilled Nursing Facility

Job Description: Social Worker – Long Term Care Skilled Nursing Facility

Role Overview and Responsibilities

The Social Worker in a long term care skilled nursing facility is responsible for providing comprehensive psychosocial support to residents, ensuring compliance with CMS and NNH guidelines. This includes conducting admission, readmission, and quarterly assessments to evaluate residents’ needs and document care plans accordingly. The Social Worker monitors all special services to guarantee that residents receive timely visits from specialists such as Podiatrists, Optometrists, and Dentists, and ensures proper follow-up appointments are scheduled and tracked.

Key duties involve scheduling and managing care plan meetings, collaborating with consulting vendors and families to develop and update individualized care plans. The Social Worker advocates for resident well-being, addresses concerns, and coordinates with interdisciplinary teams to ensure residents are seen by appropriate specialists as needed. This role also involves maintaining accurate records of assessments, service provision, and communication with external providers and family members. Strong organizational and interpersonal skills are essential for effectively managing the scheduling, follow-up, and communication required to meet regulatory guidelines and support resident quality of life.

• Conduct admission, readmission, and quarterly assessments per CMS and NNH requirements.

• Monitor and facilitate access to special services (Podiatrist, Optometrist, Dentist), including arranging follow-up appointments.

• Schedule and lead care plan meetings, engaging consulting vendors and families in resident care planning.

• Maintain documentation and ensure compliance with regulatory standards.

• Advocate for residents’ psychosocial needs and coordinate with the interdisciplinary team.

• Communicate effectively with residents, families, and external providers to ensure continuity of care.

Qualifications include a degree in social work, licensure as required by state and federal regulations, and prior experience in long term care or skilled nursing settings. Familiarity with CMS and NNH guidelines is preferred. Candidates should demonstrate strong assessment, organizational, and communication skills to manage complex care needs and regulatory requirements.