Master Social Worker

Role Description

A healthcare organization dedicated to the well-being of individuals with kidney disease seeks a compassionate and skilled Social Worker to provide essential psychosocial support services. This role involves working with patients receiving treatment within our facilities and, where applicable, those undergoing dialysis at home. Utilizing established social work principles and practices, the Social Worker will collaborate closely with the multidisciplinary healthcare team to foster positive adaptation, rehabilitation, and an enhanced quality of life for their patients.

In partnership with the interdisciplinary team, the Social Worker will educate and support staff in understanding the emotional, psychological, and behavioral aspects of chronic kidney disease and its impact on patients and their families. This ensures the delivery of comprehensive and high-quality care. The Social Worker will actively contribute to the organization's commitment to quality standards, patient satisfaction, and quality of life initiatives, participating in continuous process improvement activities aimed at achieving optimal patient outcomes. This is an entry-level position suitable for individuals holding a Master of Social Work degree.

Key Responsibilities:

Patient Assessment, Care Planning, and Counseling:

• As an integral member of the healthcare team, assess patients' psychosocial well-being, identifying strengths and needs that may influence their rehabilitation and treatment outcomes as part of a comprehensive evaluation.
• Participate in collaborative care planning with patients and the healthcare team to develop effective interventions that support rehabilitation, treatment goals, and improved quality of life.
• Utilize patient education resources, established social work theories and methods, targeted social work interventions, and quality of life assessment tools to address challenges and facilitate the achievement of patient treatment objectives.
• Provide ongoing monitoring and interventions to help patients adjust to their treatment and attain optimal psychosocial health and quality of life.
• Offer supportive counseling services to patients within the boundaries of their clinical training and relevant professional licensure.
• Deliver educational and goal-oriented counseling to patients pursuing transplantation.
• Provide information and facilitate referrals to community resources (e.g., home healthcare, vocational rehabilitation) to optimize treatment outcomes for patients.
• Maintain current knowledge of local vocational and educational rehabilitation programs and assist patients with referrals and access to these services to support their ability to maintain or gain employment or pursue education.
• Assess patients' understanding of advance directives; assist with obtaining relevant forms and information, and facilitate discussions about their wishes with the healthcare team and family/support persons as needed.
• In collaboration with physicians and nurses, participate in discussions regarding patients' decisions about Do Not Resuscitate (DNR) status within the facility to ensure informed decision-making.
• Maintain a thorough understanding of and adherence to relevant organizational Social Work policies, including documentation requirements.
• Document all MSW interactions and interventions provided to patients and/or their families.

Quality Improvement:

• Provide psychosocial support and/or targeted social work interventions to address issues related to treatment adherence, quality outcomes, and quality of life for all patients based on their individual needs.
• Participate in regular quality review meetings with the interdisciplinary team, reporting on relevant indicators such as treatment adherence, quality of life trends, and service recovery efforts.

Patient Education:

• Evaluate patients' understanding of their kidney disease to identify potential barriers to treatment adherence. Collaborate with patients, families, and the healthcare team to deliver tailored education that considers individual learning styles, communication challenges, and specific needs.
• In collaboration with the interdisciplinary team, provide comprehensive information about all available treatment options.
• Facilitate the transplant referral process and work with the interdisciplinary team on transplant waitlist management.
• Offer ongoing education to patients and families regarding psychosocial issues related to end-stage renal disease (ESRD) and available support services.
• Review patient rights and responsibilities, grievance procedures (organization and network), and relevant facility policies with patients and/or their representatives to ensure understanding of their rights and expectations.
• Collaborate with the team on appropriate quality assessment and improvement activities.

Patient Admission and Continuity of Care:

• Review patient rights and responsibilities, grievance procedures, important contact information, non-discrimination policies, DNR statements (if applicable), and address any immediate patient needs or concerns.
• Understand the referral and admission process and support the clinic in addressing patient scheduling needs to maximize adherence and adjustment.
• Interview patients requesting discharge to identify underlying reasons (e.g., transfer to hospice, relocation, dissatisfaction with services or staff) and communicate these concerns to operational leadership.

Insurance and Financial Assistance:

• Collaborate and serve as a liaison for patients with Insurance Coordinators to resolve insurance-related issues.
• In collaboration with Insurance Coordinators, provide patients with information and education about payment options for dialysis treatment (federal, state, commercial insurance, state renal programs, assistance programs, and entitlement programs).
• Communicate any changes in a patient's status that may impact their insurance coverage (e.g., transplantation, discharge, loss of coverage, extended travel) to the Insurance Coordinator.
• Refer patients to the patient billing services department for questions or concerns regarding treatment-related bills.
• Staff Collaboration:
• Assist with the interview process for new personnel as requested by the Social Work Manager or Senior Manager.
• Collaborate with administrative support staff to maintain up-to-date patient resource lists (e.g., transportation options).
• Provide training to staff on relevant psychosocial topics as needed.
• Contribute to and participate in regular team meetings, discussing urgent patient issues with staff.
• Adhere to established caseload guidelines based on relevant regulatory requirements.
• Perform other related duties as assigned.

Physical Demands and Work Environment:

The physical demands and work environment described are typical of those encountered by an employee in this role. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. Travel may be required to multiple facilities or for home visits, as applicable.

Supervision:

None

Education and Credentials:

• Master's degree in Social Work (MSW)
• Must possess a current and valid state-required license to practice social work.
• Must meet all applicable state board and licensure requirements.

Experience and Skills:

• 0 – 2 years of related experience in a healthcare setting.
• Willingness to work flexible hours, including potential for evening or weekend shifts as needed.