Social Worker, Mental Health

Location: City of Syracuse

Job Title:

Social Worker

Department:

Social Services

Reports To:

Director of Social Services

FLSA Status:

Exempt

Position Summary

The Social Worker is responsible for providing medically related social services to residents in a Skilled Nursing Facility (SNF) to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with federal, state, and local regulations. The Social Worker serves as a resident advocate, supports residents and families through adjustment and transition processes, coordinates discharge planning, and collaborates with the interdisciplinary team to ensure resident-centered care and regulatory compliance.

Resident

Assessments and Care Planning

• Complete psychosocial assessments upon admission, quarterly, annually, and as significant changes occur.
• Identify emotional, behavioral, social, financial, and environmental factors impacting resident well-being.
• Participate in the development, implementation, and evaluation of individualized care plans.
• Attend and contribute to interdisciplinary team meetings and care conferences.
• Document assessments, interventions, and progress notes in accordance with facility policy and regulatory requirements.

Resident and Family Services

• Provide counseling, support, and crisis intervention to residents and families.
• Assist residents and families in adapting to placement in the facility, illness, disability, loss, and end-of-life issues.
• Educate residents and families regarding resident rights, advance directives, and available community resources.
• Address resident and family concerns, grievances, and complaints and facilitate resolution.

Admissions and Discharge Planning

• Participate in pre-admission screenings and admission processes as assigned.
• Coordinate discharge planning from admission through discharge to ensure safe and successful transitions.
• Arrange referrals to home health agencies, hospice providers, durable medical equipment suppliers, assisted living facilities, and other community resources as needed.
• Collaborate with residents, families, physicians, nursing staff, therapists, and outside agencies to ensure continuity of care.

Regulatory Compliance and Resident Rights

• Ensure compliance with CMS regulations, state requirements, and facility policies related to social services.
• Promote and protect resident rights, dignity, choice, and quality of life.
• Assist residents with advance directives and healthcare decision-making documentation.
• Support facility survey readiness and participate during state and federal surveys.

Behavioral Health and Psychosocial Support

• Monitor residents for psychosocial concerns including depression, anxiety, adjustment disorders, behavioral concerns, and social isolation.
• Collaborate with psychiatric providers, psychologists, and behavioral health specialists as appropriate.
• Develop interventions to address psychosocial and behavioral concerns.
• Participate in behavior management and risk reduction planning.

Financial and Community Resource Coordination

• Assist residents and families with Medicaid applications, financial resource referrals, and insurance-related concerns.
• Coordinate access to community programs and supportive services.
• Maintain knowledge of local, state, and federal assistance programs available to residents.

Qualifications Education

• Bachelor's Degree in Social Work (BSW) required.
• Master's Degree in Social Work (MSW) preferred.

Experience

• Minimum one (1) year of social work experience in a healthcare setting preferred.
• Experience in skilled nursing, long-term care, rehabilitation, or post-acute care strongly preferred.
• Knowledge of discharge planning, case management, and psychosocial assessments.

Licensure/Certification

• Current Social Work license or certification as required by state law.
• Eligibility to practice social work in the state of employment.

Knowledge, Skills, and Abilities

• Thorough knowledge of CMS regulations and F‑Tags related to social services, including F656, F657, F740‑F745, and resident rights requirements.
• Strong understanding of discharge planning requirements and transition of care processes.
• Excellent interpersonal, counseling, conflict resolution, and communication…