Medical Social Worker (Steamboat Springs - Casey's Pond - PRN)
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Works under the supervision of the Director of Social Services to identify and address the psychosocial and medically related social service needs of residents, families, and significant others. Provides resident-centered assessment, care planning, discharge planning, resource coordination, advocacy, and supportive services from admission through discharge in accordance with applicable federal, state, and local standards, regulations, organizational policies, and resident rights. This is a PRN, non-supervisory position.
Supervision Received: Reports to the Director of Social Services.
Supervision Exercised: None.
Essential Functions:
1. Completes assigned social services documentation related to admissions, ongoing stays, transfers, and discharges in accordance with regulatory and organizational timelines.
2. Conducts and documents psychosocial assessments and contributes to resident-centered care plans, including BIMS, PHQ-9, social history, discharge planning, MDS-related documentation, and other assessments as assigned and within role competency.
3. Identifies medically related social service needs and provides or coordinates appropriate interventions, referrals, and follow-up.
4. Provides psychosocial support to residents, families, and significant others related to aging, adjustment, grief and loss, changes in functional status, chronic illness, end-of-life concerns, and transitions in care.
5. Serves as a resident advocate and supports resident rights, dignity, self-determination, informed choice, and access to appropriate services.
6. Participates in interdisciplinary care planning and care conferences with residents, families, nursing, therapy, providers, and other team members as assigned.
7. Coordinates discharge planning with the interdisciplinary team and arranges community-based services, equipment, transportation, follow-up care, and other resources needed to support a safe transition.
8. Communicates with hospitals, providers, case management teams, families, and community partners to support continuity of care and effective transitions.
9. Assists the Director of Social Services and other designated team members with skilled nursing admission and transition processes, including collection of social history, resident/family education, and coordination of required documentation.
10. Provides residents and families with general information and resource navigation related to Medicare, Medicaid, financial assistance, long-term care services, and community programs; refers complex eligibility or payer questions to the appropriate internal or external resource.
11. Refers residents and families to appropriate social service, behavioral health, aging, housing, transportation, benefits, and community agencies as needed.
12. Supports the PASRR, ULTC 100, PETI, and other required social services processes assigned by the Director of Social Services and consistent with training and applicable requirements.
13. Assists with documenting resident or family grievances and promptly routes concerns to the appropriate leader for investigation and resolution.
14. Coordinates or supports ancillary services and transportation needs in collaboration with the interdisciplinary team and designated administrative staff.
15. Participates in clinical meetings, resident care meetings, psychotropic medication review, Medicaid pending discussions, Resident Council support, and other committees or meetings as assigned.
16. Provides consultation and education to staff regarding resident psychosocial needs, communication approaches, family dynamics, community resources, and resident-centered care within the scope of the role.
17. Maintains accurate, timely, and confidential documentation and completes required forms, reports, and records in accordance with HIPAA, resident privacy requirements, and organizational policy.
18. Recognizes and reports suspected abuse, neglect, exploitation, mistreatment, or other safety concerns in accordance with mandatory reporting requirements and organizational policy.
19. Uses sound judgment to address routine and moderately complex resident or family concerns and appropriately escalates clinical, legal, regulatory, safety, or operational issues to the Director of Social Services or other responsible leader.
20. Provides coverage for social services functions on an as-needed basis consistent with PRN scheduling, resident needs, competency, and organizational expectations.
21. Treats residents, families, visitors, and coworkers with respect and compassion and supports Casey’s Pond’s resident-centered culture and service expectations.
22. Performs other duties as assigned that are consistent with the position and in compliance with HIPAA and organizational policy.
Education and Licensure:
1. Bachelor’s or Master’s degree in social work; or a degree in a related human services field when permitted under applicable long-term care requirements and with required professional consultation/supervision.
2. Colorado social work licensure or other authorization to practice, when required for assigned duties; LCSW preferred.
3. Current CPR certification, or ability to obtain within the timeframe required by organizational policy.
Experience:
1. Experience in long-term care, skilled nursing, post-acute care, healthcare, geriatrics, or care transitions preferred.
2. Experience working with older adults, families under stress, complex psychosocial needs, community resources, and interdisciplinary healthcare teams strongly preferred.
Requirements:
1. If car is used, must provide proof of adequate insurance coverage totaling at least $300,000 and valid Colorado driver’s license.
2. Current immunization history, after job offer and before starting job.
3. TB screening upon hire and annually per agency policy.
4. Must successfully complete required orientation, resident-rights, HIPAA, abuse prevention/reporting, infection prevention, and other assigned training.
Required Knowledge, Skills, and Abilities:
1. Knowledge of medical terminology, aging, grief and loss, end-of-life issues, crisis support, resident rights, and resident-centered care.
2. Knowledge of community resources and the ability to connect residents and families with appropriate services.
3. Strong interpersonal, verbal, and written communication skills with residents, families, physicians, coworkers, and community partners.
4. Ability to provide emotional support, elicit relevant information, navigate difficult conversations, and maintain professional boundaries.
5. Ability to work effectively with individuals from varied socioeconomic, cultural, and personal backgrounds and to provide respectful, individualized support.
6. Ability to prioritize competing needs, work independently within established guidelines, and recognize when issues require escalation or consultation.
7. Ability to maintain resident confidentiality and comply with HIPAA, organizational privacy practices, and documentation requirements.
8. Basic computer and electronic documentation skills, including proficiency with common office applications and the ability to learn facility clinical systems.
9. Working knowledge of facility emergency procedures and willingness to participate in required safety, infection prevention, and emergency preparedness training.
Equipment:
1. Daily use of multi-line phone system, fax, copy machine, shredder, postage meter, and computer.
2. Equipment also includes multi-passenger shuttle vehicles, wheelchairs, canes, walkers, and other durable medical equipment.
Working Conditions:
1. Weekend, evening, or night work as needed to ensure shift coverage.
2. This position has been classified as Resident-Facing, a position in which the incumbent could reasonably be expected to routinely interact with patients and/or patient family members. Employees in Resident-Facing positions are exposed to healthcare conditions that may require additional training, immunizations, and use of Personal Protective Equipment (PPE).
3. Possible exposure to blood-borne pathogens, various drugs, chemical, infectious, communicable diseases or biological hazards.
4. Subject to injury from falls, burns, odors, or cuts from equipment.
This description is intended to describe the essential job functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned and management retains the right to add or change the duties at any time.
