Master Social Worker

PURPOSE AND SCOPE:

As a Psychosocial Services Specialist, you will provide support to patients undergoing treatment at our facility, including those on in-center and home dialysis. You will work with the healthcare team to promote positive adjustment, rehabilitation, and quality of life for our patients.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Patient Assessment / Care Planning / Counseling

  • You will assess patients' psychosocial status, strengths, and areas of need that may affect their rehabilitation and treatment outcomes as part of their comprehensive assessment.
  • In collaboration with the patient and healthcare team, you will develop effective interventions to help them meet their rehabilitation and treatment goals.
  • You will use FKC patient education programs, established social work theory and methods, and quality of life measurement instruments to address barriers and meet patient treatment goals.
  • You will provide monitoring and interventions to help patients adjust to dialysis and achieve optimal psychosocial status and quality of life.
  • You will provide supportive counseling services to patients as permitted within the scope of their clinical training and state license.
  • You will educate and counsel patients who are seeking transplant, providing them with information and assistance throughout the process.
  • You will assist patients in accessing community resources, such as home health services and vocational rehabilitation, to facilitate optimal treatment outcomes.
  • You will maintain current knowledge regarding local vocational/educational rehabilitation programs and assist patients with referral and access to these services.
  • You will assess patient awareness of advance directives, assist with accessing advance directive forms/information, and facilitate discussion of advance directive wishes with the healthcare team and patient's family/support persons.
  • You will participate in discussions with the physician and nurse about patient DNR status, ensuring that the patient and/or family understand and make an informed decision about their care.
  • You will adhere to FMCNA Social Work Policy and Measuring Patient Physical and Mental Function Policy, including documentation.

• Quality

  • You will provide psychosocial support and Social Work Focused Interventions to address non-adherence, quality outcome, and quality of life concerns for all patients based on acuity level.
  • You will participate in monthly Quality review meetings with the interdisciplinary team, reporting on quality indicators related to adherence, such as Missed and Shortened Treatments, Quality of Life Trends, and Service Recovery.

• Patient Education

  • You will assess patient knowledge of kidney disease, identifying barriers that may affect adherence to treatment. You will work with the patient, family, and healthcare team to provide education tailored to the patient's learning style, communication barriers, and needs.
  • You will provide appropriate information about all treatment modalities with other members of the interdisciplinary team.
  • You will facilitate the transplant referral process and collaborate with the interdisciplinary team on transplant waitlist management.
  • You will provide ongoing education to patients and families regarding psychosocial issues related to End Stage Renal Disease (ESRD) and available support services.
  • You will review patient rights and responsibilities, grievance information, and other facilities policies with patients and/or their representatives to ensure understanding of these rights and expectations.
  • You will collaborate with the team on QAI activities.

• Patient Admission and Continuity of Care

  • You will review Patient Rights and Responsibilities, Grievance Procedure & Important Numbers Handout, FKC Non-discrimination policy, DNR Statement (if applicable), and address any immediate needs or concerns.
  • You will understand the referral and admission process, supporting the clinic in regard to patient needs for scheduling to maximize adherence and adjustment.
  • You will interview patients to identify root causes or concerns for discharge requests, sharing causes/concerns with operational leadership.

• Insurance and Financial Assistance

  • You will collaborate and function as a liaison for patients with Insurance Coordinators to address insurance-related issues.
  • In collaboration with Insurance Coordinators, you will provide information and education to patients about payment to dialysis (federal, state, commercial insurance, state renal programs, AKF HIPP, and entitlement programs).
  • You will collaborate with the Insurance Coordinator regarding changes to patient state that impact insurance (transplantation, discharged, loss of coverage, or extended travel).
  • You will refer patients to the patient billing solutions (PBS) department for questions/concerns regarding treatment-related bills.

• Staff Related

  • You will assist with the interview process and decision to hire new personnel if requested by the SW Manager/Senior Manager.
  • You will work with administrative support staff to maintain updated patient resource lists (e.g., transportation resources).
  • You will provide training to staff pertaining to psychosocial topics as needed.
  • You will contribute to and participate in weekly team huddles, discussing urgent patient issues with staff.
• You will adhere to work-defined caseload guidelines based on state regulatory requirements.
• You will perform other related duties as assigned.

PHYSICAL DEMANDS AND WORKING CONDITIONS

• The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Travel is required (if multiple facilities or home visits).

EDUCATION AND REQUIRED CREDENTIALS

• Masters in Social Work
• Must have state-required license
• Meets the applicable scope of practice board and licensure requirements in effect in the State in which they are employed

EXPERIENCE AND SKILLS

• 0 – 2 years' related experience