Twin Lakes Community
Social Worker for Skilled and Assisted Living
Twin Lakes Community, Trenton, New Jersey, United States
Career Opportunities with Lutherine Retirement Ministries of Alamance County NC
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Social Worker for Skilled and Assisted Living Social Worker – Skilled Nursing (STR) & Memory Care Assisted Living Hours:
8:30am - 4:30pm
Position Summary The Social Worker provides psychosocial services to residents and families in accordance with CMS regulations, state requirements, and facility policies across the Continuing Care Retirement Community (CCRC). This position is responsible for all admissions to the Memory Care Assisted Living neighborhood and serves as a backup for admissions in the Short-Term Rehabilitation (STR) Skilled Nursing neighborhood. The Social Worker ensures resident rights, psychosocial well-being, safe transitions of care, discharge planning, and interdisciplinary coordination in compliance with State and Federal Standards.
Essential Duties and Responsibilities Admissions Memory Care Assisted Living – Primary
Coordinate all admissions into the Memory Care Assisted Living neighborhood , including communication with families, referral sources, nursing, administration, and interdisciplinary team members.
Facilitate the admission process to ensure regulatory compliance, resident safety, and smooth transition into Memory Care.
Coordinate and complete all psychosocial components of Memory Care admissions.
Meet with residents and families at admission to assess psychosocial status, adjustment needs, support systems, and advance directives.
Complete psychosocial assessments and document findings in the electronic medical record (EMR) in accordance with regulatory requirements.
Educate residents and families regarding resident rights, grievance procedures, and care planning processes.
Skilled Nursing – Backup Role
Provide coverage for STR admissions as needed and coverage for LTC Social Worker as needed.
Meet with residents and families at admission and complete required psychosocial assessments and documentation in the electronic medical record (EMR).
Submit Clinical Updates to Medicare Advantage Plans
MDS Responsibilities (STR / Skilled Nursing Residents)
Participate in the MDS process in compliance with CMS requirements.
Meet with residents due for MDS assessments per the schedule provided by the MDS Nurse.
Conduct BIMS and Mood (PHQ-9) interviews to assess cognitive status and psychosocial well-being.
Accurately enter BIMS and PHQ-9 data into assessments within required timeframes.
Document resident encounters and findings in the electronic medical record (EMR).
Develop, implement, and revise psychosocial care plans based on assessed needs.
Complete PASRR
Assist families with Long Term Care Insurance Claims
Aid families with completing the Medicaid process for LTC.
Discharge Planning and Transitions of Care
Collaborate with the interdisciplinary team to ensure discharge planning begins upon admission and continues throughout the resident’s stay.
Monitor rehabilitation progress to support appropriate length of stay and level of care determinations.
Meet with residents and families to discuss discharge options, preferences, and post-discharge needs.
Arrange and coordinate post-discharge services, including home health therapy, durable medical equipment, transportation, and community resources.
Obtain physician orders for home health services, face-to-face documentation, and equipment as required.
Complete discharge summaries and required documentation in the electronic medical record (EMR).
Communicate discharge plans and updates to nursing, therapy, physicians, and the care plan team.
Conduct post-discharge follow-up calls to residents and/or families to assess adjustment, identify concerns, and ensure a safe and smooth transition of care.
Communicate identified post-discharge issues to appropriate team members for follow-up.
Memory Care Assisted Living Responsibilities
Provide ongoing psychosocial support to residents with cognitive impairment and their families.
Support families with education, coping, and decision-making related to dementia progression.
Collaborate with memory care staff to address behavioral, emotional, and social needs.
Participate in and document care planning activities in the electronic medical record (EMR).
Complete LTC insurance paperwork and submitting it for the families.
Obtain FL-2 and admission and update them on an annual basis.
Coordinate signing residents up for ancillary services and scheduling those services - dental, podiatry etc
Ensures resident register is updated on an annual basis.
Coordinates short stay admissions in MC
Grievances, Abuse Prevention, and Reporting (CMS & State Compliance)
Ensure resident rights are protected, including the right to voice grievances without fear of retaliation.
Receive, investigate, and resolve grievances in accordance with CMS regulations and TLC policies.
Document all grievances and provide written responses to residents and/or families within required timeframes.
Investigate allegations of abuse, neglect, or exploitation and ensure immediate protection of residents.
Complete and submit required abuse reports to the state per regulatory requirements.
Notify Elon Police Department of allegations that fall under the Elder Justice Act, when applicable.
Care Plan Meetings (Interdisciplinary Collaboration)
Coordinate and schedule care plan meetings in accordance with CMS requirements.
Provide written or electronic notification to residents and families regarding care plan meetings.
Encourage resident participation in care planning to the fullest extent possible.
Attend and actively participate in interdisciplinary care plan meetings.
Document care plan meetings, resident participation, and non-attendance in the electronic medical record (EMR).
Provide families with medication lists and care summaries prior to scheduled meetings.
End-of-Life Support
Provide psychosocial and emotional support to residents and families at end of life.
Assist families with immediate needs following a resident’s death and coordinate with nursing and administration.
Qualifications
Master’s degree in Social Work (MSW) required.
Current state licensure or eligibility as required.
Experience in skilled nursing, short-term rehabilitation, assisted living, or memory care preferred.
Knowledge of CMS regulations, MDS processes, and discharge planning requirements.
Strong assessment, documentation, communication, and interdisciplinary collaboration skills.
Physical and Work Environment
Position requires working across Skilled Nursing (STR) and Memory Care Assisted Living neighborhoods on a CCRC campus.
Ability to attend meetings, walk throughout campus, and meet with residents and families in various settings.
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A great place to work.
Careers At Lutherine Retirement Ministries of Alamance County NC
Share with friends or Subscribe!
Current job opportunities are posted here as they become available.
Subscribe to our RSS feeds to receive instant updates as new positions become available.
Social Worker for Skilled and Assisted Living Social Worker – Skilled Nursing (STR) & Memory Care Assisted Living Hours:
8:30am - 4:30pm
Position Summary The Social Worker provides psychosocial services to residents and families in accordance with CMS regulations, state requirements, and facility policies across the Continuing Care Retirement Community (CCRC). This position is responsible for all admissions to the Memory Care Assisted Living neighborhood and serves as a backup for admissions in the Short-Term Rehabilitation (STR) Skilled Nursing neighborhood. The Social Worker ensures resident rights, psychosocial well-being, safe transitions of care, discharge planning, and interdisciplinary coordination in compliance with State and Federal Standards.
Essential Duties and Responsibilities Admissions Memory Care Assisted Living – Primary
Coordinate all admissions into the Memory Care Assisted Living neighborhood , including communication with families, referral sources, nursing, administration, and interdisciplinary team members.
Facilitate the admission process to ensure regulatory compliance, resident safety, and smooth transition into Memory Care.
Coordinate and complete all psychosocial components of Memory Care admissions.
Meet with residents and families at admission to assess psychosocial status, adjustment needs, support systems, and advance directives.
Complete psychosocial assessments and document findings in the electronic medical record (EMR) in accordance with regulatory requirements.
Educate residents and families regarding resident rights, grievance procedures, and care planning processes.
Skilled Nursing – Backup Role
Provide coverage for STR admissions as needed and coverage for LTC Social Worker as needed.
Meet with residents and families at admission and complete required psychosocial assessments and documentation in the electronic medical record (EMR).
Submit Clinical Updates to Medicare Advantage Plans
MDS Responsibilities (STR / Skilled Nursing Residents)
Participate in the MDS process in compliance with CMS requirements.
Meet with residents due for MDS assessments per the schedule provided by the MDS Nurse.
Conduct BIMS and Mood (PHQ-9) interviews to assess cognitive status and psychosocial well-being.
Accurately enter BIMS and PHQ-9 data into assessments within required timeframes.
Document resident encounters and findings in the electronic medical record (EMR).
Develop, implement, and revise psychosocial care plans based on assessed needs.
Complete PASRR
Assist families with Long Term Care Insurance Claims
Aid families with completing the Medicaid process for LTC.
Discharge Planning and Transitions of Care
Collaborate with the interdisciplinary team to ensure discharge planning begins upon admission and continues throughout the resident’s stay.
Monitor rehabilitation progress to support appropriate length of stay and level of care determinations.
Meet with residents and families to discuss discharge options, preferences, and post-discharge needs.
Arrange and coordinate post-discharge services, including home health therapy, durable medical equipment, transportation, and community resources.
Obtain physician orders for home health services, face-to-face documentation, and equipment as required.
Complete discharge summaries and required documentation in the electronic medical record (EMR).
Communicate discharge plans and updates to nursing, therapy, physicians, and the care plan team.
Conduct post-discharge follow-up calls to residents and/or families to assess adjustment, identify concerns, and ensure a safe and smooth transition of care.
Communicate identified post-discharge issues to appropriate team members for follow-up.
Memory Care Assisted Living Responsibilities
Provide ongoing psychosocial support to residents with cognitive impairment and their families.
Support families with education, coping, and decision-making related to dementia progression.
Collaborate with memory care staff to address behavioral, emotional, and social needs.
Participate in and document care planning activities in the electronic medical record (EMR).
Complete LTC insurance paperwork and submitting it for the families.
Obtain FL-2 and admission and update them on an annual basis.
Coordinate signing residents up for ancillary services and scheduling those services - dental, podiatry etc
Ensures resident register is updated on an annual basis.
Coordinates short stay admissions in MC
Grievances, Abuse Prevention, and Reporting (CMS & State Compliance)
Ensure resident rights are protected, including the right to voice grievances without fear of retaliation.
Receive, investigate, and resolve grievances in accordance with CMS regulations and TLC policies.
Document all grievances and provide written responses to residents and/or families within required timeframes.
Investigate allegations of abuse, neglect, or exploitation and ensure immediate protection of residents.
Complete and submit required abuse reports to the state per regulatory requirements.
Notify Elon Police Department of allegations that fall under the Elder Justice Act, when applicable.
Care Plan Meetings (Interdisciplinary Collaboration)
Coordinate and schedule care plan meetings in accordance with CMS requirements.
Provide written or electronic notification to residents and families regarding care plan meetings.
Encourage resident participation in care planning to the fullest extent possible.
Attend and actively participate in interdisciplinary care plan meetings.
Document care plan meetings, resident participation, and non-attendance in the electronic medical record (EMR).
Provide families with medication lists and care summaries prior to scheduled meetings.
End-of-Life Support
Provide psychosocial and emotional support to residents and families at end of life.
Assist families with immediate needs following a resident’s death and coordinate with nursing and administration.
Qualifications
Master’s degree in Social Work (MSW) required.
Current state licensure or eligibility as required.
Experience in skilled nursing, short-term rehabilitation, assisted living, or memory care preferred.
Knowledge of CMS regulations, MDS processes, and discharge planning requirements.
Strong assessment, documentation, communication, and interdisciplinary collaboration skills.
Physical and Work Environment
Position requires working across Skilled Nursing (STR) and Memory Care Assisted Living neighborhoods on a CCRC campus.
Ability to attend meetings, walk throughout campus, and meet with residents and families in various settings.
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