Job Description

CARDINAL CARE STRATEGIES

Job Title: Social Worker – Long-Term Care / Skilled Nursing Facility

Position Summary:

The Social Worker is responsible for providing comprehensive psychosocial support to residents and their families in a long-term care or skilled nursing facility. This position focuses on promoting residents’ emotional well-being, assisting with adjustment to the facility, discharge planning, advocacy, and ensuring compliance with federal, state, and facility regulations.

Key Responsibilities:

Resident Support & Advocacy

• Conduct psychosocial assessments upon admission, quarterly, annually, and as needed.
• Provide counseling and emotional support to residents and families to assist with adjustment to long-term care and life transitions.
• Advocate for residents’ rights, dignity, and quality of life.
• Address behavioral, emotional, and social concerns in collaboration with the interdisciplinary team (IDT).

Care Planning & Coordination

• Participate in interdisciplinary care plan meetings to develop individualized resident care plans.
• Communicate regularly with nursing, therapy, dietary, and activities staff to ensure residents’ psychosocial needs are met.
• Support residents and families in understanding medical recommendations and care options.

Discharge Planning & Transitions

• Coordinate discharge planning, including referrals to community resources, home health, hospice, and other care settings.
• Educate residents and families on post-discharge needs, benefits, and available supports.
• Ensure safe, appropriate, and person-centered transitions of care.

Compliance & Documentation

• Complete required documentation in accordance with federal, state, and facility regulations (MDS Section Q, progress notes, assessments, etc.).
• Maintain confidentiality and compliance with HIPAA regulations.
• Participate in audits, surveys, and quality assurance programs as needed.

Resident & Family Engagement

• Facilitate resident and family meetings, support groups, and care conferences.
• Assist with grievance resolution and conflict mediation.
• Promote resident autonomy and involvement in decision-making.

Qualifications:

• Education: Bachelor’s or Master’s degree in Social Work (BSW or MSW) from an accredited program.
• Licensure: State licensure as required (e.g., LSW, LCSW, LMSW, or equivalent).
• Experience: Minimum of one year of supervised social work experience in a health care or long-term care setting preferred.
• Skills:
• Strong interpersonal and communication skills.
• Knowledge of aging, mental health, and psychosocial needs of older adults.
• Familiarity with Medicare, Medicaid, and community resources.
• Ability to work effectively as part of an interdisciplinary team.

Reports To:

Administrator

Work Environment:

Skilled Nursing Facility (SNF) / Long-Term Care environment; may involve occasional evening or weekend hours depending on resident and family needs.

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