Social Services & Resident Advocacy Coord.

Job Title SNF Social Services & Resident Advocacy Coordinator Department Skilled Nursing Facility (SNF) / Social Services Reports To Director of Nursing Flsa Status Non-Exempt / Hourly Pay Range $35.00 – $42.00 Work Location Southern Inyo Healthcare District Skilled Nursing Facility (33 Licensed Beds) JOB SUMMARY Serves as the District's formally designated SNF social services representative, responsible for providing and coordinating the medically related social services each resident needs to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The position performs social services assessments; identifies psychosocial needs and barriers; participates in care planning and interdisciplinary team activities; advocates for resident rights; leads social-services aspects of discharge planning and transitions; coordinates community resources and public-benefit support; assists with advance directives; and promptly escalates resident-safety, abuse, neglect, and rights concerns. The position works collaboratively with nursing, medical staff, rehabilitation, dietary, activities, administration, residents, families, representatives, community agencies, and the Long-Term Care Ombudsman. It requires sound judgment, discretion, compassion, and strong documentation and communication skills. DESIGNATION, PROTECTED TIME AND COVERAGE Because federal and California requirements apply to a 33-bed SNF regardless of its size, the following controls are part of this position: * The Incumbent Is the SNF's Designated Social Services Representative, as confirmed in writing by the Administrator and the Director of Nursing. The District Maintains One Current, Unambiguous Job Description for the Position * Required Social Services Duties Take Priority. Other Assignments, Including any Billing, Administrative, or Clerical Work, May Not Displace or Delay Required Social Services When Doing so Could Affect a Resident's Psychosocial Needs, Well-Being, or Access to Services * The Administrator and Director of Nursing Establish and Document the Protected Time for Social Services, Based on Census and Resident Needs, and Review it at Least Quarterly * A Written Coverage Plan Names a Qualified Backup for Absences, Including Care-Plan and Interdisciplinary Meetings * The Director of Nursing Monitors Completion of Required Social Services Duties and Documentation at Least Monthly and Reports Gaps to The Administrator ESSENTIAL DUTIES AND RESPONSIBILITIES 1. Social Services Assessment and Documentation * Completes the Required Social Services Interview and written Assessment for Each New Resident within the Timeframes Required by Federal and California Requirements and SIHD Policy, and Contributes to the Comprehensive Assessment * Identifies Each Resident's Psychosocial Needs, Strengths, Preferences, Concerns, Barriers, Support Systems, and Discharge Goals, Including Social, Financial, Family, Environmental, and Community Factors * Completes Required Interview Components of The Assessment (Such as Mood, Cognition, and Discharge-Planning Sections) When Trained and Assigned * Updates Assessments Quarterly, After Significant Changes, and as Needs Arise, and Documents Interventions and Follow-Up in the Resident's Medical Record * Writes Timely, Accurate, Signed Progress Notes at the Frequency Required by Applicable California Regulations and SIHD Policy 2. Care Planning and Interdisciplinary Coordination * Participates in Resident Care-Plan Meetings and Interdisciplinary Team Activities and Provides Social Services Information and Recommendations * Develops or Contributes to Resident-Centered Social Services Goals and Interventions with the Resident, Family, Representative, Physician, Director of Nursing, and Care Team * Coordinates with Nursing, Rehabilitation, Dietary, Activities, Medical Staff, and Administration and Coordinates Coverage for Meetings when Unavailable * Helps Interpret the Resident's Social, Psychological, and Emotional Needs to the Medical Staff and Care Team 100. Resident Advocacy and Resident Rights * Serves as a Resident Advocate and Helps Residents Communicate Concerns, Preferences, and Requests to Appropriate District Personnel * Informs Residents and Representatives of Resident Rights, Personal and Property Rights, and Available Resources, Consistent with Federal and California Requirements * Assists Residents and Representatives with Complaints and Grievances, Documents the Concern and Actions Taken, and Reports to the Director of Nursing and the Grievance Official Under SIHD Policy * Supports Resident Participation in Care Decisions to the Extent Permitted by the Resident's Condition and Applicable Requirements * Assists Residents with Long-Term Care Ombudsman Referrals and Communications 500. Admission, Discharge Planning and Transition Support * Participates in Admissions, Readmissions, Room Moves, and Resident and Family Inquiries as Assigned * Begins Discharge Planning at Admission and Continues throughout the Stay, Identifies Barriers to a Safe Discharge, and Develops Discharge Plans with the Resident, Family, Representative, and Interdisciplinary Team * Coordinates Referrals, Follow-Up Appointments, Transportation, Housing-Related Needs, and Transfer of Services to Community Providers * Documents Discharge Planning Activities and The Resident's Final Discharge Status * Supports Required Resident Screening and Referral Processes, Such as PASRR, as Assigned 5. Community Resources, Benefits and Public Assistance * Maintains Working Relationships with County and Community Agencies, Nonprofit Organizations, Community Health Workers, and Veterans Services, and Keeps a Current File of Community Resources * Assists Residents with Access to Housing, Food, Transportation, Financial Assistance, and Other Community Resources * Assists Residents and Authorized Representatives with Applications and Documentation for Public Benefits, Such as SSI/SSA, Disability, and Medi-Cal-Related Matters, within the Scope of the Position * Provides Residents and Families with Information on Medicare, Medi-Cal, and Other Financial Assistance Programs, and Refers Complex Eligibility or Legal Matters to a Qualified Professional or Agency * Assists with Resident Trust or Resident Account Processes in Accordance with SIHD Policy 6. Advance Directives, Representatives and Conservatorship Coordination * Assists Residents in Accessing and Completing Advance Directive Documents and Coordinates Required witnessing or Validation Processes * Identifies Residents who Need Help Understanding or Communicating Advance-Care-Planning Preferences and Coordinates with Appropriate Representatives * Coordinates With Authorized Representatives, Agents Under Durable Powers of Attorney, Conservators, Family Members, and County or Court Representatives, and Maintains Documentation of Those Communications * Escalates Legal or Decision-Making Questions to The Administrator or a Qualified Professional 7. Psychosocial Support and Referral * Provides Supportive Interventions within the Scope of the Position's Qualifications and Helps Residents Adjust to Admission, Changes in Health, Changes in Living Environment, and Discharge * Identifies Psychosocial Concerns That Need Referral To Qualified Behavioral-Health, Clinical, or Other Professional Services, Makes Referrals, and Documents Follow-Up * Maintains Professional Boundaries and Does Not Provide Services Outside the Incumbent's Licensure, Certification, Training, or Authorized Scope 8. Resident Safety, Mandatory Reporting and Regulatory Escalation * Immediately Reports witnessed or Reported Suspected Abuse, Neglect, Exploitation, Rights Violations, or Unsafe Discharge to the Director of Nursing and the Administrator, and Completes Required Reports to the Ombudsman, Law Enforcement, Adult Protective Services, and the California Department of Public Health in the Manner and time Required By Law (Including Form SOC 341 where Applicable) * Does Not Independently Investigate Matters Outside Assigned Authority and Maintains Confidentiality throughout Reporting and Investigation * Supports Readiness for CDPH and CMS Surveys, Participates In Survey Activities And Corrections As Assigned, And Reports Compliance Concerns Through The SIHD Escalation Process * Reports Incidents and Accidents Immediately And Participates In Fire Safety and Disaster-Preparedness Drills 1. Training, Committees and Other Responsibilities * Participates in Staff Orientation and In-Service Education Related to Resident Psychosocial Needs and Resident Rights, and in the SNF's Quality Assurance and Performance-Improvement Activities as Assigned * Serves on Committees as Assigned and Attends In-Service Training Before Tasks that May Involve Exposure to Blood, Body Fluids, Infectious Materials, or Hazardous Chemicals * Performs Other Duties Reasonably Related to the Position and Consistent with the Incumbent's Qualifications and Department Needs 10. Confidentiality, HIPAA and Compliance * Complies with HIPAA and SIHD Privacy and Security Policies and Accesses, Uses, and Discloses Protected Health Information Only as Authorized and Necessary for Assigned Duties * Complies with SIHD Personnel, Safety, Infection-Control, and Compliance Policies and Procedures * Immediately Reports Suspected Privacy, Security, or Compliance Concerns through the Appropriate SIHD Reporting Process KNOWLEDGE, SKILLS AND ABILITIES Knowledge of * Social Services Principles, Psychosocial Assessment, and Resident-Centered Care Planning * Long-Term Care Environments and the Needs of Older Adults and Residents with Physical, Cognitive, and Behavioral-Health Conditions * Resident Rights, Advocacy, Advance Directives, and Surrogate Decision-Making And Conservatorship Concepts * Discharge Planning, Community Resources, and County and Public-Benefit Programs, Including Medicare and Medi-Cal * Federal and California SNF Regulations Relevant to Social Services, Mandatory Reporting, and Survey Processes * Confidentiality, HIPAA, and Professional Boundaries Ability To * Build Effective, Respectful Relationships with Residents, Families, and Representatives, Including in Difficult or Emotional Situations * Advocate Professionally for Resident Needs and Identify Psychosocial Barriers * Coordinate Community Resources and Facilitate Interdisciplinary Communication * Document Interventions Accurately and on Time, and Manage Sensitive and Confidential Information * Communicate with County and Community Agencies * Recognize Issues Requiring Professional, Administrative, or Regulatory Escalation and Act Promptly * Organize Work, Set Priorities, and Function Effectively Under Time and Regulatory Deadlines * Work as a Team Member and Follow SIHD Policies, Including Attendance, Timekeeping, Safety, and Standards of Behavior MINIMUM QUALIFICATIONS Education and Experience (one of the following) * Pathway A: Bachelor's Degree in Social Work or a Human Services Field (Such as Sociology, Gerontology, Psychology, Rehabilitation Counseling, or Special Education) * Pathway B: Associate Degree or Equivalent Plus at Least One (1) Year of Experience in Social Services, Case Management, Human Services, or a Long-Term-Care or Health Care Setting Professional Certification and 6-Month Development Expectation * Completion of a Social Services Designee certification or training program approved by SIHD Human Resources and the Administrator Within Six (6) Months of Hire, under an HR- and DON-Approved Development Plan, unless the Incumbent already holds an Equivalent Qualification * The Plan May Identify the Program, Completion Target Date, and Periodic Progress Reviews. Completion within Six Months is an Employment Expectation Unless SIHD Formally Approves an Exception based on Documented Circumstances * Nothing in this Section Prevents SIHD from Establishing a More Stringent Requirement for a Particular Regulatory or Departmental Need Other Requirements * Satisfactory Completion of The Conditions of Employment Under HR-032, Including Criminal Background Clearance as Required by California Law for Long-Term-Care Personnel and Consistent with HR-028 And HR-029, Drug Test, Tuberculosis and Other Required Health Clearance, Physical Exam, and Satisfactory References * Satisfactory Exclusion/Sanction Screening, as Applicable (HR-030) * Ability to Meet CPR/BLS and any Other Certification, Immunization, or Health-Clearance Requirements Applicable to Long-Term-Care Personnel The incumbent may not use the title “Social Worker” or provide services reserved for licensed or credentialed professionals unless the incumbent holds the required license or credential. PREFERRED QUALIFICATIONS The following are not required but will be given favorable consideration: * Bachelor's Degree in Social Work (BSW) or a Master of Social Work (MSW), or an Associate Clinical Social Worker (ASW) or Licensed Clinical Social Worker (LCSW) Credential, which also Supports Meeting the Federal Qualified Social Worker Standard and California Supervision Requirements * 2+ Years of Supervised Social Work Experience in a SNF, Hospital, or Other Health Care Setting Working Directly with Individuals * Current California RN or LVN License, Particularly for the Case-Management and Care-Coordination Aspects of the Position * Experience with MDS Assessments (Including Interview Components), Care Planning, and Discharge Planning * Knowledge of Medicare, Medi-Cal, SSI/SSA, Veterans Benefits, Advance Directives, and Conservatorship Processes * Experience with the Long-Term Care Ombudsman Program, Mandated-Reporter Processes, and CDPH/CMS Survey Readiness * Experience in a Rural or Small-Facility Setting and Bilingual Ability in a Language Spoken by SIHD's Residents and Families REQUIRED TECHNICAL KNOWLEDGE AND TRAINING * Working Knowledge of Federal and California SNF Requirements for Social Services, Resident Rights, Grievances, Advance Directives, Discharge Planning, and Abuse Reporting * Working Knowledge of the Electronic Health Record and Documentation Requirements for Social Services * Within the First Six (6) Months of Employment, Completion of SIHD-Designated SNF Training, Including Abuse and Neglect Prevention and Reporting, Resident Rights, Dementia Care, Behavioral Health, Infection Prevention, HIPAA, and Compliance and Ethics * Completion of the Initial Training and Competency Validation Under HR-038 and Department Orientation Under HR-036 WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS The position is primarily indoors in a skilled nursing facility and requires frequent sitting, with occasional walking and standing, hand use for writing and computer work, and frequent hearing, speaking, and reading. The position may occasionally require lifting or carrying items, such as policy manuals and resident records, of up to approximately 10 pounds. The incumbent works with residents who may have cognitive, medical, or behavioral needs, and may encounter upset or hostile residents or family members, and exposure to infectious materials, requiring standard precautions and appropriate protective equipment. Reasonable accommodation will be considered consistent with applicable requirements.