Medical Social Worker

Fresenius Medical Care•Martinsville, VA

10d•$51,000 - $85,000

About The Position

Provides psychosocial services to patients receiving in-center and, where applicable, home dialysis. Works with the healthcare team to promote patient adjustment, rehabilitation, and quality of life, and helps staff understand the emotional, psychological, and behavioral effects of chronic kidney disease on patients and their families. Supports quality indicators, quality assessment and improvement activities, patient satisfaction, and initiatives intended to help patients achieve quality goals. The Medical Social Worker assesses psychosocial needs and strengths, contributes to care planning, provides counseling and education within the scope of their training and state license, and helps patients access community, vocational, educational, and financial resources. The role supports patient education, transplant referral and waitlist management, advance-care planning discussions, continuity of care, and insurance-related coordination. It also participates in interdisciplinary quality reviews and team activities, provides staff training on psychosocial topics as needed, and follows applicable social work policies and caseload guidelines.

Requirements

Master’s degree in Social Work.
State-required license.
2–5 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 plans, interventions, rehabilitation goals, treatment goals, and quality-of-life improvement.
Use patient education programs, social work methods and interventions, and quality-of-life measurement instruments to address barriers and support treatment 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, including educational and goal-directed counseling for patients seeking transplant.
Connect patients and the care team with community resources, including home health services and vocational rehabilitation.
Maintain knowledge of local vocational and educational rehabilitation programs and assist patients with referrals and access.
Assess patient awareness of advance directives and assist with information, forms, 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 by patients and families.
Follow social work and patient physical and mental function policies, including documentation requirements; document interactions and interventions with patients and families.
Provide psychosocial support and focused interventions addressing non-adherence, quality outcomes, and quality-of-life concerns according to patient acuity.
Participate in monthly interdisciplinary quality reviews and report indicators related to adherence, missed or shortened treatments, quality-of-life trends, and service recovery.
Assess patients’ kidney-disease knowledge and barriers to treatment adherence, and tailor education to their learning styles, communication barriers, and needs.
Provide information about treatment modalities with the interdisciplinary team and facilitate 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.
At admission, review patient rights and responsibilities, grievance procedures and important numbers, the non-discrimination policy, and the DNR statement when applicable; address immediate needs and concerns.
Support referral and admission processes and patient scheduling to promote adherence and adjustment.
Interview patients requesting discharge to identify concerns or underlying causes, such as hospice transfer, relocation, or dissatisfaction, and share them with operational leadership.
Work with insurance coordinators to address patient insurance issues and educate patients about dialysis payment options and assistance programs.
Notify the insurance coordinator of patient status changes that may affect coverage, including transplantation, discharge, loss of coverage, or extended travel.
Refer patients to the patient billing solutions department for treatment-bill questions or concerns.
Assist with interviewing and hiring decisions for new personnel when requested by the Social Work 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, raising urgent patient issues with staff.
Follow caseload guidelines based on state regulatory requirements and perform other related duties as assigned.