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Villa Maria Nursing Ctr & Rehab
Job Location: Hialeah Gardens, FL

Summary & Objective

The Social Worker coordinates discharge planning for residents and helps manage their healthcare and psychosocial needs by acting as a liaison between them and the physicians / nurses as related to their progress and status while in the facility. The Social Worker also assists residents in getting access to community resources and programs.

Essential Functions

  • Interviews new admissions to complete Psychosocial History and Verifies demographic information on face sheet within 3 days of admission (72 hours).
  • Provides education to resident and/or family regarding Resident Rights, Advance Directives, community resources, insurance coverage, appeal rights, grievance and abuse program and documents in clinical software.
  • Enter and/or update all Advance Directives on face sheet and identify need for a Guardian.
  • Attends Care Plan meeting with interdisciplinary team to discuss plan of care.
  • Conducts family conference meetings as needed.
  • Initiates discharge instruction sheet and completes assigned areas.
  • Discharge planning to the community with but not limited to home health, durable medical equipment, outpatient services referrals, Long Term Care, Assisted Living Facility and Skilled Nursing Facility if applicable.
  • Coordinates and obtains authorization from insurance company for all procedures, appointments and transportation as needed if applicable.
  • Provides Notice of Medicare Non-Coverage to resident and/or responsible party and obtains signature 48 hours prior to discharge if applicable.
  • Follows appeal process and ensures all documentation is submitted in a timely manner to assigned agency if applicable.
  • Documents resident progress notes in the Medical Record as needed.
  • Participates in daily management team meetings to discuss resident status, census changes, and resident complaints or concerns if applicable.
  • Obtains timely insurance re-certifications and provides weekly updates verbal/written for continued stay authorization and enters into billing software if applicable.
  • Coordinates efforts regarding any abuse allegations while adhering to the Abuse policy in collaboration with Administrator, Risk Manager and interdisciplinary team
  • Adhere to Grievance policy which includes an updated log and investigative documentation if applicable.
  • Complete progress notes/assessments - quarterly, annually and when significant changes occur if applicable.
  • Complete Resident Assessment Instrument process which includes MDS, CAA and individualized Care Plans if applicable.
  • Provide residents/responsible party with Care Plan invitations if applicable.
  • Provides counseling to resident and/or family.
  • Completes enrollment for Medicare programs for qualified residents if applicable.
  • Ensure Pre Admission Screening and Resident Review (PASRR) is appropriately completed.

*Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

Other Duties

  • Ensures proper room change policy is followed in collaboration with Nursing and Admissions departments if applicable.
  • Ensures Social Services Department is prepared for inspections/surveys.
  • Provides facility staff education on Resident Rights, Grievance policy and Abuse policy annually and/or as needed.
  • Promotes positive employee engagement, teamwork, and mutual respect and safety work practices.
  • Maintain mandatory skill updates
  • Comply with all policies, local, state and federal laws and regulations
  • Perform other duties as assigned

Supervisory Responsibility

  • May serve as an interim department leader depending on need.

Physical Requirements

  • Must be able to lift and/or move up to 50 pounds and push/pull up to 250+ pounds, walk, climb stair or ladders, stand on feet for extended periods of time, etc.


The job description is not designed to cover or contain a comprehensive listing of activities duties or responsibilities that are required of the employee. Other duties, responsibilities and activities may change or be assigned at any time.

EEOC Statement

CHS provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.



Knowledge & Experience Requirements

  • MSW, BSW or Bachelor's Degree in a Human Services field including but not limited to Sociality, Special Education, Rehabilitation Counseling, and Psychology
  • 1 year of supervised Social Work experience in a healthcare setting
  • CPR Certification
  • Must have knowledge of computer office/clinical software
  • Must be able to read, write and understand the English language




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