Social Services Coordinator

Assists in planning, organizing, implementing, conducting and evaluating the overall operation of the facility’s Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations, and the facility’s established policies and procedures.

All facilities must provide medically related social services to residents.  It is not required that a qualified social worker necessarily provide all these services, except as required by State law. The regulations do not require a Social Worker when a facility has equal to or less than 120 beds. The Social Services Coordinator must possess: 1–2 years of experience in a healthcare clerical or staffing role (preferably in a long-term care or nursing home setting).

• A minimum of a bachelor’s degree from an accredited college.

• A bachelor’s degree in social work or healthcare.
• 1 year of experience working in the medical field
• 1 year of experience working in a skilled nursing facility

• The Social Services Coordinator will work with the Social Services Director in the planning, developing, organizing, implementing, conducting, and evaluating the social services programs of this facility.
• The Social Services Coordinator will meet with administration, medical and nursing staff, and other related departments in planning social services, as directed.
• Conduct assigned resident assessments/evaluations including the completion of designated sections of the facility’s Minimum Data Set (MDS).
• Participate in developing and revising residents’ care plans.
• Work with residents/responsible parties to participate in the development of their care plans.
• Schedule various meeting with residents and/or responsible parties, including, but not limited to care plan meetings, care conferences, and discharge planning meetings.
• Participate, coordinate and assist residents with their discharge planning. This includes ordering recommended durable medical equipment (DME), coordinate post-discharge services (i.e. home health services, caregiver services, care coordination, physician follow-up visits, etc. as related to the needs of the discharge plan), coordinating transportation, coordinating caregiver support and services, and communication with resident representatives. 
• Communicate with the resident’s attending providers related to discharge timelines, resident’s status, updates in conditions, requesting necessary provider orders, and communicating resident’s requests and preferences.
• Assist residents and/or the resident representative in locating and accessing financial, legal, and other community resources (including assistance with benefit programs, care coordination enrollment, and completing Medicaid applications).
• Complete accurate and timely documentation related to social services actions and interactions in each resident’s medical record.
• Assist and participate with facility policy development and annual reviews in order to positively impact the quality of care delivered to residents.
• Work with the facility’s IDT in ensuring that staff members are knowledgeable about Resident’s Rights and encourage staff to maintain and enhance each resident’s dignity in recognition of each resident’s individuality.
• Engage in Advance Care Planning for assigned residents upon admission, and make sure that any Advance Health Care Directives are reviewed with the resident/resident representative on a regular basis. The Social Worker will ensure that staff members are made aware of the resident’s code status and end-of-life wishes and will assist with informing and educating residents and their representatives about health care options and ramifications.
• Conduct resident mood and behavior evaluations, develop mood and behavioral care plans, coordinate the implementation of mood and behavioral interventations.
• The Social Services Coordinator will ensure that residents who display mental illness, or psychosocial difficulties such as coping with grief and loss, have access to appropriate treatment and resources.
• Assists residents in voicing and obtaining resolution to grievances. Reviews complaints and grievances made by the resident and makes a written/oral report to the Social Services Director and/or Administrator indicating what action(s) were taken to resolve the complaint or grievance.  Follows facility’s established procedures.
• Participate in the facility’s QAPI program.
• Provide and arrange needed mental and psychosocial counseling services.
• Coordinate end-of-life care and support. Assist with hospice education, enrollment, and coordination.
• Makes arrangements for obtaining items, such as clothing and personal items.
• Understands, participates, and coordinates the use of psychotropic medications and participates in the facility’s psychotropic medication program.
• Perform and complete any other tasks as assigned.