Long Term Care Social Worker / Case manager

Case Manager / Social Worker

We are looking for a Case Manager / Social Worker to become a vital part of our team at Sunny View Nursing Home , a small 57-bed facility serving both long- and short-term skilled patients.

This integrated role focuses on optimal by bridging clinical case management and psychosocial support. The Case Manager / Social Worker assesses residents' physical, mental, and social needs , develops individualized care plans , coordinates services with the interdisciplinary team and families, and advocates for residents to ensure the highest practical level of physical, mental, and psychosocial well-being and quality of life. This role acts as a central point of contact, identifying barriers to care, and maintaining communication to improve health outcomes and continuity of services.

Key Responsibilities

Care Coordination & Clinical Management

• Assessment & Care Plan Development : Conduct comprehensive physical, mental, and social assessments to understand residents' unique needs, preferences, and abilities. Create and implement individualized care plans in collaboration with residents, families, and the interdisciplinary healthcare team.
• Monitoring & Evaluation : Regularly monitor residents' progress, evaluate the effectiveness of the care plan, and make necessary adjustments to improve outcomes.
• Coordination of Services : Arrange and coordinate services such as medical appointments, therapies, personal care, home visits, and complete Admission Assessments and discharge planning .
• Liaison & Communication : Serve as the primary point of contact , facilitating communication and collaboration among residents, families, healthcare providers, and community agencies.

Financial & Resource Advocacy

Psychosocial Support & Resident Rights

Documentation & Quality Assurance

Essential Skills and Qualifications