Master Social Worker - MSW

Fresenius Medical Care•Berwick, PA

About The Position

This is an entry-level Master Social Worker role providing psychosocial services to patients treated by the facility, including in-center and home dialysis patients when applicable. The role uses social work theory and accepted social work practices to support patients’ adjustment, rehabilitation, treatment outcomes, and quality of life. In collaboration with the interdisciplinary healthcare team, the Social Worker helps staff understand the emotional, psychological, and behavioral effects of chronic kidney disease on patients and families. The role supports Fresenius Kidney Care quality indicators, outcomes, quality assessment and improvement activities, patient satisfaction, and quality-of-life goals. It includes assessment and care planning, counseling, patient and family education, community-resource referrals, quality reviews, admission and continuity-of-care support, insurance and financial-assistance coordination, 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.
Must meet the applicable scope-of-practice board and licensure requirements in the state of employment.
0–2 years of related experience.

Responsibilities

Assess patients’ psychosocial status, strengths, and needs that may affect rehabilitation and treatment outcomes as part of the comprehensive patient assessment.
Collaborate with patients and the interdisciplinary healthcare team on care planning and interventions to support rehabilitation, treatment goals, and quality of life.
Use patient education programs, social work methods and interventions, and quality-of-life measurement instruments to address barriers and support patient goals.
Monitor patients and provide interventions to support adjustment to dialysis and optimal psychosocial status and quality of life.
Provide supportive counseling within the scope of clinical training and state licensure, and provide goal-directed counseling to patients seeking transplant.
Refer patients to community resources, including home health and vocational rehabilitation, and assist with access to educational and vocational rehabilitation programs.
Assess patient awareness of advance directives, assist with access to related information and forms, and facilitate discussion of advance directive wishes 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, including documentation requirements, and document interactions and interventions with patients and families.
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, quality-of-life trends, and service recovery.
Assess patients’ kidney-disease knowledge and barriers to treatment adherence; tailor education to patients’ learning styles, communication barriers, and needs.
Provide information about treatment modalities and support transplant referrals and transplant waitlist management with the interdisciplinary team.
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.
At admission, review patient rights, grievance procedures, important contact information, non-discrimination policy, and DNR statement when applicable; address immediate needs and concerns.
Support referral and admission processes, including scheduling needs that may affect adherence and adjustment.
Interview patients requesting discharge to identify underlying causes or concerns and share them with operational leadership.
Liaise with Insurance Coordinators to address patient insurance issues and provide information about dialysis payment options and assistance programs.
Inform Insurance Coordinators of patient status changes that may affect insurance, such as transplantation, discharge, loss of coverage, or extended travel.
Refer patients to the Patient Billing Solutions department for questions or concerns about treatment-related bills.
Assist with interviews and hiring decisions for new personnel when requested by the SW Manager or Senior Manager.
Work with administrative support staff to maintain current patient resource lists, such as transportation resources.
Provide staff training on psychosocial topics as needed and participate in weekly team huddles, discussing urgent patient issues with staff.
Follow caseload guidelines based on state regulatory requirements and perform other related duties as assigned.