Contract Social Worker (SNF)

Job Description

The Social Worker plays a vital role in supporting residents and their families throughout their stay in our skilled nursing facility. Working independently or in collaboration with the Case Manager RN , the Social Worker develops comprehensive post-acute care and discharge plans for residents who face personal, social, or environmental barriers to recovery and overall well-being.

What You'll Do

• Develop and implement individualized discharge and post-acute care plans in collaboration with the interdisciplinary team.
• Support residents and families in navigating the transition from skilled nursing care to home or other care settings.
• Screen, assess, and provide resources related to social determinants of health (e.g., transportation, housing, food insecurity).
• Serve as an expert on community and social service resources available to residents and families.
• Coordinate referrals to Behavioral Health services as appropriate for counseling or outpatient care.
• Provide education and support around housing stability, food access, and other essential needs.
• Coordinate transportation arrangements for residents' medical or personal appointments.
• Assist families in understanding the emotional and practical implications of the resident's medical condition and recovery process.
• Conduct financial assessments and connect residents / families to applicable financial or community assistance programs.
• Arrange for in-home care services, durable medical equipment (DME), and community-based supports as needed for safe discharge.

What You'll Need

Job Details