JOB OBJECTIVE:
Reporting to the Care Neighborhoods Administrator, the Care Neighborhoods Social Worker supports the provision of care coordination in a manner that recognizes the resident, family, medical team, and neighborhood staff as essential partners in the resident's care. The Care Neighborhood Social Worker will work with residents in the care neighborhoods by identifying their psychosocial, mental and emotional needs along with providing, developing, and/or aiding in the access of services to meet those needs. The Care Neighborhoods Social Worker serves as Admissions Coordinator for the Care Neighborhoods.
ESSENTIAL DUTIES:
Job Duties
- Admission Coordination/Admissions
a. The Care Neighborhoods Social Worker serves as Admissions Coordinator and is responsible for managing the entire admission process for all potential residents in the Care Neighborhoods, including but not limited to evaluating medical needs, reviewing insurance coverage, conducting tours, interviewing prospective residents and their families, and ensuring all necessary paperwork is completed to facilitate a smooth transition into the neighborhoods while adhering to relevant regulations and maintaining positive relationships with referral sources. Other functions as requested by the interdisciplinary team.
- Supports viability of the Care Neighborhoods through stable and sustained occupancy. Anticipates openings and works to proactively to fill available beds. Alerts care neighborhood administrator and nurse managers of potential openings. Works with the Marketing team to garner external referrals in times of need.
- Maintains knowledge of bed status and potential admissions in the care neighborhoods and provides daily updates in stand up. Keeps bed tracker and referral tracker up to date.
- Ensures that the admission packet is understood and signed by residents or responsible party upon admission to the care neighborhoods. Completes and processes all admission paperwork with residents and/or responsible parties.
- Develops a comprehensive social history and completes a psychosocial assessment that includes the residents' problems and strengths and preferences for residents admitted to the care neighborhoods.
- Orients care neighborhood residents and families to Saint John's - its services, service limitations, and residents' rights.
- Helps residents and their families (in their social, racial, ethnic, and cultural context) cope with the immediate effects of the decision to move to Saint John's or to transfer within the continuum of care at Saint John's. Provides daily visits/contact to newly admitted residents to guide their acclimation to their new surroundings and provide support.
- Follows and monitors hospitalized independent living residents for potential admission to the care neighborhoods.
2.
Communication/Planning/Documentation
- Completes comprehensive written admission, quarterly and change of condition assessments, utilizing and expanding on the State and Federal minimum standards (Minimum Data Sets) within the electronic medical record.
- Develops and maintains a working relationship with the interdisciplinary team.
- Coordinates care conferences in the care neighborhoods to discuss and coordinate the care plan/individual service plan, allowing for open communication, collaborative decision-making, and ensuring the best possible quality of life for the resident by addressing their needs and concerns
- Works directly with residents and families on Advanced Directives in the care neighborhoods. Ensures any Advanced Directives are in place per facility policy and completes the activation process when indicated.
- Assures that progress notes meet the standards established by Federal and State governments, including resident status, response to and evaluation of social service programs and activities within required timeframes.
- Serves as a resource to residents/families on Medicare and Medicaid benefits. Assists with the application for benefits.
- Psycho-social and Behavioral Health
- Facilitates resident/family access to resources to support their psychosocial/emotional needs such as the Alzheimer's Support Group and Emotional Support resources recommended by Saint John's.
- Conducts depression, dementia or other types of screenings as needed.
- Helps residents and family prepare for and cope with losses, including aging and death.
- Coordinates access to behavioral health services.
- Manages concerns and grievances.
- Discharge Planning
- Is responsible for managing the transition of residents leaving the care neighborhoods, including coordinating necessary post-discharge services, communicating with family members, arranging transportation, and ensuring a smooth handover to community-based care providers, all while advocating for the patient's needs and ensuring their safety and well-being after discharge
- Provides linkage with appropriate community resources by maintaining knowledge of other systems, making referrals, and identifying unmet needs (e.g., recreational transportation, adaptive phone equipment, financial questions, crisis management services, durable medical equipment,etc.) inside and in the greater community.
- Professionalism
- Maintains the confidentiality of proprietary business, financial, health, personal or other information concerning residents, employees, consultants, prospects, and operations and where appropriate complies with the Health Insurance Portability and Accountability Act (HIPAA) as well as organizational and departmental standards.
- Assures that all resident rights are maintained. Report any violations of suspected deviations according to Saint John's policy.
- Leads investigations of allegations of any form of Misconduct according to State and Federal regulations. Documents, findings, and reports to the State as required by law.
- Works cooperatively with residents, clients, families, volunteers, visitors, and all levels of staff throughout the organization. Accepts delegation from multiple disciplines.
- Completes all mandatory in-services within established timeframes; attends all meetings, seminars, etc. as directed.
All Employees Must Foster Person Centered Care/Professional Integrity and Responsibility
- Act with honesty and openness in all resident/family/ responsible party and employee contacts. Function as Saint John's Communities Ambassadors to maintain a working environment that values respect, fairness, inclusiveness, and integrity. Promote a responsible workplace in recognition and support of the boundaries of people with whom we work and serve.
- Demonstrate commitment to the person-first philosophy that gives residents the power of choice. Function as a community member within the principles and practices that guide care and services through knowing and honoring the person before the task. In this vein, we will:
- Foster relationships between residents, family and staff.
- Know each person as an individual who can and does make a difference.
- Nurture the spirit as well as the mind and body.
- Promote growth and development for all.
- Create an environment that meets the physical, social, emotional, intellectual, spiritual and occupational needs of individuals and the community.
KNOWLEDGE, SKILLS, ABILITIES QUALIFICATIONS:
Knowledge:
- Familiar with State and Federal regulations/guidelines for primary work area: Skilled Nursing Facility (Windsor); CBRF (Stratford and Canterbury) and RCAC (Towers).
- Knowledge of community services such as home health and proven skills in discharge planning.
- Understands the MDS system and is able to complete the Social Work component (Windsor).
Skills:
- Possesses basic computer skills with some proficiency in the use of Microsoft Outlook, Word and Excel.
Abilities:
- Demonstrates dependability and reliability in adhering to an established work schedule. Able to work flexible hours to meet scheduling requirements.
- Demonstrates performance efficiency in managing workload in order to meet established deadlines. Able to adapt to changing organizational needs.
- Displays excellent written and verbal communication skills. Knows and follows existing lines of communication and authority. Exhibits a warm, cheerful, caring manner when interacting with residents, families, co-workers, and other guests at Saint John's.
- Must be professional in actions, dress appropriately to the position, have excellent customer service skills, and desire to work with and serve older adults.
- Must demonstrate the ability to comprehend and follow established procedures. Able to multi-task and work independently while performing various job duties.
- Must have demonstrated ability to identify a resident's social/emotional needs and be able to intervene effectively.
Qualifications:
- Must be a graduate of an accredited School of Social Work Services and currently licensed as a Social Worker in the State of Wisconsin. Master's degree in social work, preferred.
- Must have at least 2 years of experience working with a geriatric/rehabilitation population. One year experience in a Medicare and Medicaid certified long term care facility with strong knowledge of OBRA guidelines.
- Must have experience working with dementia and behavioral health residents/patients.
- Must be able to read, speak and write English.
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Saint John's On The Lake
Aug 13, 2025