Social Services Assistant/ Discharge Planner

Ayers Health and Rehab Center – Trenton, FL

Ayers Health and Rehab Center is seeking a compassionate, organized Social Services Assistant / Discharge Planner to support residents and families throughout their stay and ensure safe, timely, and well-coordinated discharges. This role works closely with the Social Services Director and interdisciplinary team to address psychosocial needs, care transitions, and continuity of care.

This is a full-time position with benefits and plays a vital role in resident satisfaction, compliance, and successful outcomes.

Serves as a resident and family liaison by assisting with social services, admissions support, and discharge planning. Supports residents through illness, transition, and adjustment while ensuring compliance with federal, state, and facility requirements.

• Assist the Social Services Director with resident grievances, care coordination, and psychosocial support

• Work with residents and families to support adjustment to illness, disability, institutional living, and end-of-life concerns

• Coordinate discharge planning from admission through discharge to ensure timely, medically appropriate transitions

• Assist residents and families in arranging post-discharge services, equipment, transportation, and community resources

• Issue transfer, discharge, and non-coverage notices in accordance with federal regulations

• Complete and maintain accurate, timely Social Services documentation

• Assist with psychosocial assessments, social histories, BIMS, PHQ-9s, and care planning as needed

• Participate in Utilization Review and communicate coverage determinations when applicable

• Educate residents and families on advance directives and care planning

• Support admissions processes, tours, and coordination as needed

• Maintain professional communication with residents, families, staff, and outside agencies

• Attend required meetings and remain compliant with all facility, company, state, and federal policies

• Perform other duties as assigned

• High school diploma or equivalent required

• Experience in social services, discharge planning, or a healthcare setting strongly preferred

• Experience working with individuals or families in crisis strongly preferred

• Ability to handle emotionally demanding situations, including illness, disability, and death

• Strong organizational, communication, and documentation skills

• Self-motivated, professional, compassionate, and team-oriented

• Flexible schedule availability, including occasional evenings or weekends as needed

• Must meet all local health regulations, including drug screening and background checks

Requires walking, standing, sitting, bending, reaching, lifting, and fine hand coordination. Must be able to communicate effectively with residents, families, staff, and providers, respond to overhead pages, and maintain a professional appearance and positive demeanor.

• Full-time position with benefits

• Medical, dental, and vision insurance

• Daily Pay option

• Tuition assistance

• Employee referral bonus program

• 401(k) with employer match

• Paid time off 

• Supportive leadership and collaborative care team

• Meaningful work making a difference in residents’ lives

Job Duties Disclaimer:
Duties listed are not all-inclusive and may be adjusted based on facility needs.

Equal Opportunity Employer (EOE):
Ayers Health and Rehab Center is an Equal Opportunity Employer.