Social Worker Job at Saint John's On The Lake in Milwaukee

Overview

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 Neighborhoods 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.

Responsibilities

• Admission Coordination / Admissions: serves as Admissions Coordinator and is responsible for managing the entire admission process for all potential residents in the Care Neighborhoods, including 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.
• Support occupancy viability: maintains stable occupancy, anticipates openings, alerts care neighborhood administrator and nurse managers of potential openings, and works with Marketing to garner external referrals in times of need.
• Bed status and admissions tracking: maintains knowledge of bed status, provides daily updates, and keeps bed and referral trackers up to date.
• Admission documentation: ensures the admission packet is understood and signed by residents or responsible party; completes and processes all admission paperwork.
• Social history and assessment: develops a comprehensive social history and completes a psychosocial assessment that identifies residents' problems, strengths, and preferences.
• Orientation: orients residents and families to Saint John's services, limitations, and residents' rights.
• Transition support: helps residents and families cope with the move or transfer within Saint John's, providing daily visits/contact to guide acclimation and support.
• Hospitalized residents: follows and monitors hospitalized independent living residents for potential admission to the care neighborhoods.

Communication / Planning / Documentation

• Documentation: completes comprehensive written admission, quarterly, and change of condition assessments, utilizing state and federal standards within the electronic medical record.
• Interdisciplinary collaboration: develops and maintains working relationships with the interdisciplinary team.
• Care planning: coordinates care conferences to discuss and coordinate the care plan / individual service plan, ensuring the resident's needs and concerns are addressed.
• Advanced Directives: works with residents and families on Advanced Directives; ensures directives are in place per policy and activated when indicated.
• Progress notes: ensures notes meet federal and state standards, including status, response to and evaluation of social services within required timeframes.
• Benefits assistance: serves as a resource on Medicare and Medicaid benefits and assists with benefit applications.
• Psycho-social and Behavioral Health: facilitates access to resources (e.g., Alzheimer's Support Group, emotional support) and conducts screenings as needed; assists with coping with losses; coordinates access to behavioral health services; manages concerns and grievances.
• Discharge planning: manages transitions, coordinates post-discharge services, communicates with families, arranges transportation, and ensures safe handover to community-based providers.
• Community linkage: maintains knowledge of community resources and makes referrals for unmet needs (e.g., transportation, equipment, crisis services).

Professionalism

• Confidentiality and compliance: protects resident, employee, and organization information and complies with HIPAA and standards; maintains resident rights and reports violations as required.
• Investigations and collaboration: leads investigations of misconduct per regulations; documents and reports to state as required; works cooperatively with residents, families, volunteers, and staff; accepts delegation from multiple disciplines.
• Professional conduct: completes mandatory in-services, attends meetings; fosters a person-centered care environment and professional integrity; promotes respectful and inclusive practice; supports boundaries of all involved.
• Person-centered philosophy: commits to person-first principles, building relationships, nurturing the spirit and mind, and meeting physical, social, emotional, intellectual, spiritual, and occupational needs.

Knowledge, Skills, Abilities, Qualifications

Knowledge :

• Familiar with state and federal regulations/guidelines for primary work areas: Skilled Nursing Facility (Windsor); CBRF (Stratford and Canterbury) and RCAC (Towers).
• Knowledge of community services such as home health and discharge planning; understands the MDS system and can complete the Social Work component (Windsor).

Skills :

• Basic computer skills with proficiency in Microsoft Outlook, Word and Excel.

Abilities :

• Demonstrates dependability and reliability, flexible hours, and ability to meet scheduling requirements.
• Manages workload to meet deadlines and adapts to changing needs.
• Excellent written and verbal communication; follows established lines of communication and authority; maintains a warm, caring manner with residents, families, and staff.
• Professional in actions; presents well; strong customer service; able to work with older adults.
• Able to comprehend and follow procedures; capable of multi-tasking and working independently.
• Ability to identify residents\' social/emotional needs and intervene effectively.

Qualifications :

• Must be a graduate of an accredited School of Social Work and currently licensed as a Social Worker in the State of Wisconsin; Master\'s degree preferred.
• Minimum 2 years of experience with a geriatric/rehabilitation population; one year in a Medicare/Medicaid certified long-term care facility with strong knowledge of OBRA guidelines.
• Experience with dementia and behavioral health residents/patients.
• Must be able to read, speak and write English.