Social Services Director

Edgewood Health & Rehab

Job Description: Social Services Director

Department: Social Services
Reports To: Administrator
Position Type: Full-Time

Position Summary

The Social Services Director is responsible for assessing the social, emotional, psychological, and discharge-planning needs of residents admitted to Edgewood Health & Rehab. This individual will develop and maintain individualized, written plans of care that address each resident’s identified needs, preferences, and goals.

The Social Services Director serves as a liaison between residents, families, facility staff, and community resources to promote resident well-being, support successful transitions of care, and ensure residents are treated with dignity, respect, and compassion. The ideal candidate must be organized, detail-oriented, dependable, and able to communicate effectively with residents, families, and all facility departments.

Essential Duties and Responsibilities

1. Resident Assessment and Care Planning

• Complete social services assessments for residents upon admission and as required throughout their stay.
• Identify residents’ social, emotional, psychological, financial, and discharge-planning needs.
• Develop, implement, and update individualized written plans of care based on assessment findings.
• Participate in interdisciplinary care plan meetings and collaborate with other departments to establish and achieve resident-centered goals.
• Monitor residents’ adjustment to the facility and provide support as needed.
• Maintain accurate, complete, and timely documentation in accordance with facility policies and applicable regulations.

2. Family and Resident Support

• Establish and maintain positive relationships with residents and their families.
• Serve as a primary point of contact for social services concerns, family questions, and resident adjustment issues.
• Provide emotional support, counseling within the scope of qualifications, and assistance with problem-solving.
• Communicate professionally and compassionately with families regarding resident needs, changes in circumstances, and discharge plans.
• Assist residents in exercising their rights, expressing preferences, and participating in decisions regarding their care.
• Address concerns and grievances promptly and communicate unresolved issues to the Administrator as appropriate.

3. Discharge Planning and Community Resources

• Coordinate discharge planning with residents, families, nursing, therapy, and other members of the interdisciplinary team.
• Identify and refer residents and families to appropriate community resources, including home health services, hospice, transportation, financial assistance, counseling, and other support services as needed.
• Assist residents and families in identifying available services and resources to support safe transitions from the facility.
• Collaborate with healthcare providers, referral agencies, and community organizations to facilitate continuity of care.
• Document discharge plans, referrals, follow-up arrangements, and related communications.

4. Interdepartmental Communication and Teamwork

• Work closely with nursing, therapy, activities, dietary, admissions, business office, and administration to address resident needs.
• Participate in interdisciplinary meetings, quality assurance activities, and other facility meetings as assigned.
• Communicate relevant resident concerns and changes in social needs to appropriate team members.
• Promote a cooperative, professional, and resident-focused work environment.
• Assist with resolving concerns through timely communication, appropriate follow-up, and teamwork.

5. Compliance and Recordkeeping

• Maintain organized, accurate, and confidential social services records.
• Ensure documentation and services are completed within required time frames.
• Follow applicable federal and state regulations, resident rights requirements, confidentiality standards, and facility policies.
• Assist with survey preparation, audits, corrective action plans, and quality improvement activities related to social services.
• Report suspected abuse, neglect, exploitation, or other safety concerns promptly in accordance with facility policy and applicable reporting requirements.
• Maintain confidentiality of resident information and comply with HIPAA and other applicable privacy requirements.