Master Social Worker - MSW

Fresenius Medical Care•Santa Fe, NM

About The Position

The Master Social Worker provides psychosocial services to patients treated by the facility, including in-center and home dialysis patients where applicable. Using social work theory and accepted practice methods, the role works with the healthcare team to promote patients’ adjustment, rehabilitation, and quality of life. The social worker helps staff understand the emotional, psychological, and behavioral effects of chronic kidney disease on patients and families, and supports quality indicators, quality assessment and improvement activities, patient satisfaction, and quality-of-life outcomes. This is an entry-level MSW role. The position assesses patients’ psychosocial needs and strengths, contributes to individualized care planning, provides supportive and goal-directed counseling within the scope of clinical training and state licensure, and connects patients with community, vocational, educational, transplant, and other support resources. It also supports patient education, admission and continuity of care, insurance and financial-assistance coordination, quality reviews, and staff education. The position has no supervisory responsibilities. Travel may be required for multiple facilities or home visits, if applicable.

Requirements

Master’s degree in Social Work.
Must hold the state-required license and meet applicable state board scope-of-practice and licensure requirements.
0–2 years of related experience.

Responsibilities

Assess patients’ psychosocial status, strengths, and needs as part of comprehensive assessment and care planning.
Collaborate with patients and the interdisciplinary healthcare team to identify interventions that support rehabilitation, treatment goals, and quality of life.
Use patient education programs, social work methods and interventions, and quality-of-life measures to address barriers and treatment goals.
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 license, and provide education and goal-directed counseling to patients seeking transplantation.
Refer patients to community resources, including home health services and vocational rehabilitation, and help them access vocational and educational rehabilitation programs.
Assess patient awareness of advance directives, provide access to forms and information, and facilitate discussions with the healthcare team and support persons when needed.
Participate with the physician and nurse in discussions of patient DNR status to support informed decisions by patients and families.
Follow applicable social work and patient-function policies, document interactions and interventions, and maintain required records.
Provide psychosocial support and social work interventions addressing non-adherence, quality outcomes, and quality-of-life concerns according to patient acuity.
Participate in monthly interdisciplinary quality review meetings and report on adherence indicators, missed or shortened treatments, quality-of-life trends, and service recovery.
Assess patients’ kidney disease knowledge and learning barriers, and tailor education to their learning styles, communication needs, and circumstances.
Provide information about treatment modalities, facilitate transplant referrals, and collaborate on transplant waitlist management.
Educate patients and families about psychosocial issues related to ESRD and available support services; review patient rights, responsibilities, grievance information, and facility policies.
Collaborate with the team on quality assessment and improvement activities.
Review required rights, grievance, non-discrimination, DNR, and contact information with patients during admission, and address immediate concerns.
Support admission and scheduling processes to address patient needs and maximize adherence and adjustment.
Interview patients requesting discharge to identify underlying concerns and share them with operational leadership.
Coordinate with insurance coordinators on patient insurance issues, payment options, coverage changes, and relevant patient circumstances; refer treatment-billing questions to Patient Billing Solutions.
Assist with interviewing and hiring decisions when requested by the Social Work Manager or Senior Manager.
Work with administrative support staff to keep patient resource lists current.
Provide staff training on psychosocial topics as needed and participate in weekly team huddles, raising urgent patient issues with staff.
Follow caseload guidelines based on state regulatory requirements and perform other related duties as assigned.