Description

You will provide psychosocial interventions, care coordination, and discharge planning for residents in a skilled nursing facility, working as part of an interdisciplinary team to address emotional and social needs and ensure smooth transitions.

Requirements

• MSW or equivalent degree in social work
• Experience in skilled nursing or long-term care setting
• Knowledge of psychosocial assessment and care planning
• Familiarity with federal/state regulations (e.g., MDS/RAPS)
• Ability to work effectively in an interdisciplinary team

Responsibilities

• Provide direct psychosocial interventions to residents and families
• Create and update person-centered care plans
• Coordinate discharge planning and act as liaison with community referrals
• Document assessments, interventions, and progress in medical records
• Facilitate advance care planning and end-of-life counseling