Assessment of patients' and families' strengths and limitations with regard to response to rehabilitation and discharge needs.
Counseling around life events, medical and financial concerns.
Conduct Interdisciplinary conferences for subacute and long term residents on a weekly basis.
Participate in daily Clinical Team meetings.
Ensure that Medicare guidelines are followed in the provision of social work services for a 120-bed subacute and skilled nursing facility.
Completion of MDS reviews
Coordinate discharges with other stakeholders (therapy, nursing, MDS, managed care plans, visiting nurses, private duty vendors, financial planning, DME, O2, etc.).
Supervision of social work field internships for graduate students.
Working with residents and families on adjustment to illness: dementia, cancer, joint replacement, etc.
Education and training of staff on managing patient behaviors related to managing resident behaviors and family concerns.
Collaboration with team members to ensure quality patient care.
Preparation of insurance reviews to obtain necessary reimbursement for services, appeals, denials, etc.
Referring patients to community services appropriate to their needs.
Serve as a liaison to community agencies. Hosting educational gatherings to build partnerships.
Serving as Grievance Officer for facility.
Addressing care concerns brought forth by families.
Member of the Quality Assurance Committee to assure compliance with quality standards and appropriate follow up.