Master Social Worker - MSW

Fresenius Medical Care•National City, CA

About The Position

Provides psychosocial services to patients receiving in-center and home dialysis, as applicable, using social work theory and accepted practice methods. Works with the healthcare team to promote patients’ adjustment, rehabilitation, and quality of life, and helps staff understand the emotional, psychological, and behavioral effects of chronic kidney disease on patients and families. Supports quality indicators, patient satisfaction and quality-of-life goals, and improvement activities. As part of the interdisciplinary team, assesses patients’ psychosocial status, strengths, and needs; participates in care planning; provides monitoring, interventions, and supportive counseling within the scope of clinical training and state licensure; and helps patients address barriers to treatment and rehabilitation goals. Provides education and counseling on topics including transplantation, kidney disease, treatment modalities, patient rights, advance directives, and available support services. Connects patients with community and vocational resources and assists with advance-directive discussions and informed decisions regarding DNR status. Supports quality activities through psychosocial interventions, participation in monthly quality reviews, and reporting on indicators such as missed or shortened treatments, quality-of-life trends, and service recovery. Supports admission and continuity of care by reviewing patient rights, policies, and grievance procedures; identifying concerns that may affect discharge or transfer; and communicating relevant issues to operational leadership. Works with insurance coordinators on coverage and payment questions, and refers billing questions to the patient billing solutions department. May assist with hiring when requested, maintain patient resource lists, provide staff training on psychosocial topics, participate in weekly team huddles, and discuss urgent patient issues with staff. Follows applicable social work policies, documentation requirements, and state-regulated caseload guidelines. Performs other related duties as assigned. Travel is required if working across multiple facilities.

Requirements

Master’s degree in Social Work.
Must have the state-required license.
2–5 years of related experience.

Responsibilities

Assess patients’ psychosocial status, strengths, and needs that may affect rehabilitation and treatment outcomes.
Collaborate with patients and the healthcare team on care planning and effective interventions to support treatment goals and quality of life.
Use patient education programs, social work methods, focused interventions, and quality-of-life measures in assessment and care planning.
Monitor patients’ adjustment to dialysis and provide interventions to support psychosocial status and quality of life.
Provide supportive counseling within the scope of clinical training and state licensure, including goal-directed counseling for patients seeking transplant.
Connect patients and the care team with community resources, including home health and vocational or educational rehabilitation services.
Assess awareness of advance directives, help patients access information and forms, and facilitate discussions with the care team and family or support persons as needed.
Participate with the physician and nurse in discussions of patient DNR status to support informed decisions.
Document social work interactions and interventions and comply with relevant social work and patient-function policies.
Provide psychosocial support and focused interventions addressing non-adherence, quality outcomes, and quality-of-life concerns.
Participate in monthly interdisciplinary quality reviews and report on adherence, missed or shortened treatments, quality-of-life trends, and service recovery.
Assess patient knowledge of kidney disease and tailor education to learning style, communication barriers, and needs.
Provide information about treatment modalities and coordinate transplant referrals and waitlist management with the interdisciplinary team.
Educate patients and families about psychosocial issues related to ESRD, support services, patient rights, responsibilities, grievance procedures, and facility policies.
Collaborate with the team on quality assessment and improvement activities.
Support patient admission and continuity of care by reviewing rights, grievance procedures, policies, and immediate needs; identify and communicate causes of discharge requests or concerns.
Liaise with insurance coordinators on insurance issues and educate patients about dialysis payment options and assistance programs.
Notify insurance coordinators of patient status changes that affect coverage and refer treatment billing questions to the patient billing solutions department.
Assist with interviewing and hiring personnel when requested by the Social Work Manager or Senior Manager.
Maintain patient resource lists with administrative support staff, provide staff training on psychosocial topics as needed, participate in weekly team huddles, and discuss urgent patient issues with staff.
Follow caseload guidelines based on state regulatory requirements and perform other related duties as assigned.