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Social Worker - Nursing Home

Company: SSM Health
Location: Madison
Posted on: September 15, 2018

Job Description:

Description Role Purpose: Responsible for resident admission and discharge process. Works closely with residents and their families to facilitate a smooth transition. Role Responsibilities: Professional Responsibility: Advocate for persons related to elder abuse, domestic violence, homelessness or unique situations. Uphold resident rights to be treated with dignity and respect by all. Report any violations to your supervisor, DON, or Administrator for guidance on appropriate authorities to get involved. Assist in resolving concerns (OFIs) and serve as a liaison for residents, families and staff. Admission Coordination: Coordinate necessary admission paperwork according to State and Federal Guidelines. Discuss, explain, and obtain signatures on admission agreement, Medicare authorizations, Resident Rights, and other required paperwork with resident/agent. Provide Medicare mandated paperwork to resident/agent according to CMS guidelines. Review PASARR screen upon admission for accuracy and contact appropriate agency is a Level 2 screening is required at any time. Maintain accuracy of PASARR screen- updating and/or reviewing with each change of condition. Educate and assist residents and families with completion of Advanced Directives including Health Care Powers of Attorney, Guardianships, and Living Wills. Discharges Planning: Maintain an awareness of local resources commonly needed in the discharge planning. Educate resident and families on what services are available for them in the community. Coordinate with multidisciplinary team members to facilitate a smooth transition from the Care Center to the residents chosen destination. Set up necessary services for the resident in their home or other setting. Make referrals as appropriate/requested. Care plans: Develop RFS care plan for each resident that is individualized to meet their specific needs and unique preferences. Update the care plan quarterly or as needed so the care plan accurately reflects each resident at all times. Coordinate care conference times with residents, families and the multidisciplinary team members. Ensure that all are invited to care conferences in a timely manner. Meeting attendance: Attend Medicare Meetings, Department Meetings, General Staff Meetings, appropriate Behavior Management Meetings, Neighborhood Meetings, Palliative Care Meetings, Care Conference Meetings, Fall Meetings, and other meetings as assigned. Education: Attend seminars, webinars, and in house in-services to meet the Wisconsin Licensure standard (30 credit hours every 2 years) for Social Work Certification. Keep track of these hours and be able to show proof of attendance. In addition attend all Mandatory In-services provided within the facility. --- Documentation: Documentation is to be completed in ECS. Documentation must be accurate, timely and professionally written. Care plans must be updated at least quarterly or with any significant change (relating to RFS). Quarterly progress notes must be completed. Charting should always reflect an accurate picture of the resident and their current situation. Close attention should be paid to behavioral charting, mood charting, and discharge planning charting. Customer Service: Support and uphold our Mission, Vision and Values in all of your interactions. Understands and uses AEPC standards in dealing with residents, families, and potential residents. Provides emotional support to residents and families during times of condition change, loss, death, and transition. Demonstrate a strong sense of advocacy. Follow facility guidelines regarding customer service and professional conduct. Safety: Comply with Safety policies and procedures. Participate appropriately in drills. Observe residents for safety including wandering and inappropriate behavior and intervene if needed. Report and complete necessary incident reports. Utilize infection control measures, including hand washing. Participate in mandatory immunization programs. Caseload: Appropriately maintain caseload of designated residents in regards to care plans, documentation, resident needs, family needs, discharge planning, and assessment. Assist other RFS team members with their caseload as needed. May assist with Admission Coordinator position from time to time if indicated. --- Resident Personal Needs: Coordinate with family and resident to ensure the personal needs of the resident (appropriate clothing, etc) are met. Characteristics: Genuine interest in aging and care of chronically ill and their families. Interest in rehabilitation of the debilitated aged. Knowledge and understanding of basic needs of the elderly from a psycho social perspective. Working knowledge of the needs of those who may be memory impaired. Knowledge of Medicare/Medicaid guidelines. Interest in continuing education. Strong advocacy skills. Strong organizational skills. Good time management skills. Ability to prioritize. Good written and oral communication. Maturity. Empathy. Good judgment. Flexibility. Reliability. Positive attitude. Good general physical and emotional health. Strong sense of professionalism in all interactions. Qualifications Minimum Qualifications: Bachelors degree in social work or a related field Licensure as a Certified Social Worker by the State of Wisconsin Ability to communicate professionally with coworkers, residents, their families, and agencies Efficiently and accurately enter data and utilize a computer for a variety of activities; deal with time pressures and stress Must be able to perform basic math (add, subtract, multiply, divide, fractions, decimals, and percentages) Preferred Qualifications: Previous experience, especially in a geriatric setting, is preferred St. Mary's Care Center St. Mary's Care Center is a 184-bed skilled nursing and rehabilitative facility. Affiliated with St. Mary's Hospital, St. Mary's Care Center is recognized as a leader among Wisconsin nursing homes. We are committed to providing an excellent quality of life for each resident. St. Mary's Care Center offers award-winning clinical services in a caring and compassionate atmosphere. Many residents make the Care Center their year-round home. Some are with us for memory care, others for short-term rehabilitation services. In all cases, residents and their families take active roles in developing person-centered care plans.

Keywords: SSM Health, Madison , Social Worker - Nursing Home, Healthcare , Madison, Wisconsin

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