Description The responsibility of the Social Services/Discharge Planner is to act as an advocate for the residents. The Social Services/Discharge Planner protects vulnerable residents and ensures that their best interest is observed and helps them to find remedies to their situation. The Social Services/Discharge Planner also holds the responsibility of monitoring and completing the steps of residents' discharges. Note: All employees of Cascadia Healthcare are required to submit and be cleared to work in the facility per each state’s specific background check requirements prior to contact with patients/residents. Essential Functions • Assesses the psychosocial status of patients related to the patient’s illness and environment and communicates findings to the registered nurse. • Performs the tasks of a discharge planner working with families, patients, physicians and staff to ensure proper documentation and orders are in place and patients have everything they need for a successful discharge. • Actively participates in discharge planning and advises on issues relating to resident’s/patient’s practical and enviro mental needs post-discharge. • Carries out social evaluations and plans person-centered intervention based on evaluation findings. • Maintains clinical documentation on all patients referred to social work. • Provides information and coordinates referral services for residents/patients and families/caregivers regarding resident’s/patient’s practical and environmental needs. • Provides information to residents/patients or families/caregivers regarding community agencies and other available services. • Serves as liaison between residents/patients or families/caregivers and community agencies. • Maintains collaborative relationships with facility co-workers to support resident/patient care. • Participates in the development of the total plan of care and case conferences for residents/patients referred to social services, as required. • Assists physician and other team members in understanding significant social and emotional factors related to residents’/patients’ health problems. • Addresses resident behaviors to prevent harm to themselves or others. • Coordinates medication review regimen to determine gradual dose reduction to the lowest possible dose. Knowledge/Skills/Abilities • Demonstrates good verbal and written communication, and organization skills. Requirements Licenses/Certification • LCSW, LSW, or MSW license preferred. • Must have a valid driver’s license. Experience • Experience in post-acute/ skilled nursing preferred.