Master Social Worker - MSW

Fresenius Medical Care•Santa Fe, NM

About The Position

Provides psychosocial services to patients receiving in-center and, where applicable, home dialysis. Works with the healthcare team to support patients’ adjustment, rehabilitation, treatment goals, and quality of life. In collaboration with the interdisciplinary team, helps staff understand the emotional, psychological, and behavioral effects of chronic kidney disease on patients and families. Supports Fresenius Kidney Care quality indicators, outcomes, quality assessment and improvement activities, patient satisfaction, and quality-of-life goals. This is an entry-level MSW role. The position assesses patients’ psychosocial needs and strengths, contributes to care planning, provides counseling and education within the scope of clinical training and state licensure, and connects patients with community resources. It also supports transplant education and referrals, advance-care planning discussions, patient rights and admission processes, continuity of care, and insurance and financial-assistance coordination. The Social Worker participates in quality reviews and improvement activities, provides staff education as needed, and addresses urgent patient concerns with staff. Travel may be required for work across multiple facilities or home visits, if applicable.

Requirements

Master’s degree in Social Work.
State-required license and compliance with 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 healthcare team on care planning and interventions to support treatment goals, rehabilitation, and quality of life.
Use patient education programs, social work methods, focused interventions, and quality-of-life measurement instruments 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, and goal-directed education and counseling for patients seeking transplantation.
Provide information about and refer patients to community resources, including home health services and vocational or educational rehabilitation programs.
Assess patient awareness of advance directives, help patients access information and forms, and facilitate discussions with the healthcare team and family or support persons as needed.
Participate with the physician and nurse in discussions of patient DNR status to support informed decisions by the patient or family.
Document social work interactions and interventions and follow applicable social work and patient-function policies.
Provide psychosocial support and focused interventions addressing adherence, quality outcomes, and quality-of-life concerns.
Participate in monthly interdisciplinary quality reviews and report on adherence indicators, missed or shortened treatments, quality-of-life trends, and service recovery.
Assess patients’ knowledge of kidney disease and barriers to treatment adherence; coordinate education tailored to patients’ learning styles, communication barriers, and needs.
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 and responsibilities, grievance information, and facility policies with patients or their representatives.
Support admission and continuity-of-care processes, review applicable handouts and policies, and address immediate needs or concerns.
Interview patients requesting discharge to identify concerns or underlying causes and share them with operational leadership.
Coordinate with insurance staff to address coverage issues and educate patients about dialysis payment sources and assistance programs.
Notify the Insurance Coordinator of patient-status changes that may affect insurance, and refer treatment-billing questions or concerns 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 keep patient resource lists current and 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.