Master Social Worker

Fresenius Medical Care•Juana Diaz, PR

About The Position

Provides psychosocial services to in-center and home dialysis patients, using social work theory and accepted practice methods. Works with the healthcare team to promote 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, quality assessment and improvement activities, patient satisfaction, and process improvement. As an interdisciplinary team member, assesses patients’ psychosocial status, strengths, and needs; participates in care planning; provides supportive and goal-directed counseling within the scope of clinical training and state licensure; and helps patients access education, community resources, vocational rehabilitation, advance directive information, and transplant referrals. Documents assessments and interventions and supports patients’ adjustment to dialysis and treatment goals. The role also supports quality reviews and patient education, including education about kidney disease, treatment modalities, patient rights, grievances, and available support services. It contributes to patient admission and continuity of care, insurance and financial assistance coordination, staff training, team huddles, and resolution of urgent patient concerns. Travel may be required when supporting multiple facilities. The position has no supervisory responsibilities.

Requirements

Master’s degree in Social Work.
State-required social work 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 interdisciplinary healthcare team on care planning and effective interventions.
Use patient education programs, social work methods, focused interventions, and quality-of-life measures to address barriers and treatment goals.
Monitor patients’ adjustment to dialysis and provide supportive counseling within the scope of clinical training and state licensure.
Provide education and goal-directed counseling to patients seeking transplant.
Refer patients to community resources, including home health services and vocational or educational rehabilitation programs.
Assess patient awareness of advance directives and assist with forms, information, and discussions with the healthcare team and family or support persons.
Participate with the physician and nurse in discussions of patient DNR status to support informed decisions.
Document patient and family interactions and interventions in accordance with applicable policies.
Provide psychosocial support and focused interventions addressing non-adherence, quality outcomes, and quality-of-life concerns.
Participate in monthly interdisciplinary quality review meetings 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 support transplant referrals and waitlist management.
Educate patients and families about psychosocial issues related to ESRD and available support services.
Review patient rights and responsibilities, grievance information, and facility policies with patients or their representatives.
Collaborate with the team on quality assessment and improvement activities.
Review admission materials and address immediate patient needs or concerns.
Support referral, admission, and scheduling processes to promote adherence and adjustment.
Interview patients requesting discharge to identify underlying concerns and share them with operational leadership.
Liaise with insurance coordinators about insurance issues and educate patients about dialysis payment and assistance programs.
Inform insurance coordinators about patient status changes that may affect coverage and refer billing questions to the patient billing solutions department.
Assist with hiring interviews and decisions when requested by the Social Work Manager or Senior Manager.
Work with administrative support staff to maintain current patient resource lists.
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.