Social Services Director

Description

Job Overview:

To manage the medically related social service program of the facility in accordance with established facility protocol, standards of practice, and current federal and state regulations, to ensure the residents’ highest possible levels of physical, mental, and psychosocial well-being. 

Key Responsibilities:

Patient and Family Support:

Provide emotional support and guidance to patients and their families throughout their stay at the facility.

Collaborate with the interdisciplinary team to address any psychosocial and emotional needs of the patients.

Promote a safe, clean environment in which the residents may live.

Education:

Educate residents and families/significant others regarding their rights and responsibilities, effective problem solving, and the extent of community, health, and social services that are available to them, including those necessary for effective discharge planning.

Educate staff regarding cultural diversity and each staff member’s importance when caring for residents. 

Educate staff regarding residents’ rights and how to recognize and prevent abuse, neglect, and mistreatment. 

Ensure or provide support and education to residents/family members/significant others to assist in their understanding of placement and facility issues in addition to referring them to the appropriate social service agencies when the facility does not provide the needed services.

Ensure understanding of and compliance with all policies, procedures, rules, and regulations regarding resident rights including assisting in exercising their rights.

Attend and provide in-service training programs, as indicated.

Coordination with MDS and Care Plan Meetings:

Participate in the development of a written, interdisciplinary plan of care for each resident that identifies the psychosocial needs/issues of the resident, the goals to be accomplished for those needs/issues, and the appropriate social worker interventions.

Coordinate with the MDS/DON to conduct comprehensive assessments of patients’ medical, social, and emotional needs.

Organize and lead care plan meetings involving the patient, their family, and relevant healthcare professionals to create individualized care plans.

Coordinate, download to PointClickCare, or any other electronic health record or office applications all available completed assessments, and care plan forms, and complete all social-specific UDA’s 

Ensure the integration of patient preferences and goals into the care plan development process.

Provide therapeutic interventions to assist residents in coping with their transition and adjustment to a long-term care facility, including their social, emotional, and psychological needs.

Process and Prepare Notice of Medicare Non-Coverage (NOMNC) forms in accordance with facility and regulatory guidance.

File in a timely manner, any patient appeals to the appropriate entities and keep facility, patient, and patient families abreast of updates and final communication on appeal.

Participate in regularly scheduled Medicare meetings being prepared with the appropriate documentation.

Medicaid Application and Renewal Management:

Assist patients and their families in completing and submitting Medicaid applications.

Provide guidance and support throughout the Medicaid application process.

Collaborate with relevant agencies to ensure timely and accurate submission of Medicaid applications.

Monitor and manage the timely renewal of Medicaid applications for eligible patients, ensuring all required documentation is prepared and submitted accurately and on time.

Bed Management and Availability:

Monitor bed availability and manage the placement of incoming patients in collaboration with the admissions team.

Coordinate with the nursing staff to ensure efficient bed turnover and appropriate placement of patients based on their care needs.

Maintain accurate records of bed availability, transfers, and admission.

Maintain a facility wait list as needed and communicate to facility when beds become available.

Discharge Patient Follow-up

Coordinate the resident discharge planning process and make referrals for appropriate home care services prior to the resident’s return to the community.

Conduct thorough 30-day follow-ups with discharged patients to ensure their smooth transition and continued well-being.

Address any post-discharge concerns or issues that may arise and provide appropriate referrals and resources as needed.

Collaborate with the clinical team to develop and implement comprehensive discharge plans for