Social Services Director (SNF Post Acute Case Manager)

• Starting at the time of SNF Admission, the SNF Case Manager oversees the SNF stay with a focus on patient experience, length of stay management and transition planning to ensure delivery of high-quality care during the SNF stay, and safe timely transition to the next level of care upon discharge.
• Responsible for coordinating and managing the transitions and care efficiencies of patients residing in a SNF for either short-term or long-term care.
• Develops a comprehensive social history and assessment of the resident that includes problems and strengths, special needs and preferences (social, religious and/or cultural) and the implications for the care plan.
• Assists the resident/family with the transition to the new environment, orients the resident/family to the facility, services, limitations and resident’s rights.
• Meets regularly with patients and families at the SNF to evaluate needs, gaps in services, progress related to care plan goals and readiness for transition to the next level of care.
• Participates in the development of the individual’s care plan, including advocating for and linking patients to additional resources needed to achieve positive outcomes.
• Initiates and maintains communication and collaboration with SNF staff, physicians, and other caregiving disciplines to develop, implement and evaluate a transition plan of care for each patient (i.e., medication reconciliation, post-discharge appointments and services).
• Facilitate interdisciplinary meetings related to antipsychotics and gradual dose reduction efforts, trauma informed care and other psychosocial services as needed.
• Strong team collaboration required. Actively participates in departmental staff and annual policy review meetings and monthly quality assurance meetings.
• Ensures that any Advanced Directives are complete and maintained and placed in resident charts.
• Completes all mandatory documentation in a timely (determined) fashion as established by applicable regulations.
• Maintains confidentiality of all admission information and resident records following HIPPA and the community’s Code of Ethics.

• →Social Services Degree with 5+ years of experience or LVN with 5+ years of experience.

• →Excellent oral, written and interpersonal skills. Must present a professional manner and be able to deal with situations that may be stressful.
• →Must have experience working with Title 22 and OBRA Regulations, including, but not limited to, Medicare, PPS, MDS, Care Planning and HIPPA.
• →Ability to multi-task and prioritize effectively, and work closely with residents, families and staff.

Please apply to this job or look at other available positions using the link below!

https://visitorchards.com/careers/current-openings/

Our company is committed to a diverse and inclusive workplace. We are an equal opportunity employer that does not discriminate based on race, national origin, gender, gender identity, sexual orientation, protected veteran status, disability, age, or other legally protected status.

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