Acute Social Worker-LICSW Adult Kidney Transplant

Fairview Health Services•Minneapolis, MN

8d•Onsite

About The Position

Fairview is looking to hire a Licensed Independent Clinical Social Worker (LICSW) to join our Adult Kidney Transplant team. This is a 0.8 FTE, benefit-eligible position, approved for 64 hours every two weeks. As a member of the Solid Organ Transplant interdisciplinary team, the Social Worker provides comprehensive psychosocial services and interventions to transplant candidates, recipients, living donors, families, and caregivers. This role supports patients and their support systems throughout the entire transplant journey, helping them strengthen coping skills, navigate complex psychosocial needs, and maintain effective social functioning. Consistent with CMS Conditions of Participation for Transplant Programs, social work services are provided throughout all phases of transplant care, including pre-transplant evaluation, waitlist management, inpatient hospitalization, transplantation, discharge planning, post-transplant follow-up, and long-term outpatient care. The ideal candidate will bring strong clinical social work skills, excellent communication and collaboration abilities, and an interest in supporting patients and families through the complex medical, emotional, and psychosocial aspects of kidney transplantation. The Social Worker has primary responsibility for evaluating the psychosocial status and needs of transplant candidates, families, and recipients in both inpatient and outpatient settings. They provide ongoing consultation, counseling, education, advocacy, resource coordination, and crisis intervention throughout the transplant continuum. The Social Worker collaborates closely with physicians, advanced practice providers, nurses, pharmacists, psychologists, financial coordinators, and other members of the interdisciplinary transplant team to optimize patient outcomes and ensure compliance with regulatory and accreditation standards. This individual practices independently within the scope of their licensure and professional standards, assumes leadership in patient care and program development, participates in quality improvement initiatives, and requires minimal supervisory guidance.

Requirements

Master of Social Work
1 year Experience working in a healthcare or related setting
LICSW Mstrs Deg Clinical or Provisional LICSW State of Minnesota Upon Hire

Nice To Haves

3 years Experience working in a healthcare or related setting

Responsibilities

Attends daily in person interdisciplinary care team rounds
Conducts thorough psychosocial assessments with patients and/ or their surrogate decision makers
Helps the care team navigate and mediate complex psychosocial dynamics
Is well versed in the surrogate decision maker policy and assists care team members with identifying surrogate decision makers according to the policy
Communicates frequently with the interdisciplinary team to ensure continuity and effective coordination of care
Provides emotional support and counseling surrounding adjustment to sudden illness, grief/bereavement and end of life planning
Addresses social determinants of health and assists with connecting patients to needed resources in the community such as chemical dependency treatment, domestic violence resources, housing stabilization services, mental health services, food shelves, transportation, financial assistance etc.
Arranges and facilitates in person care conferences as needed to support patients and their families surrounding navigating complex medical decision-making processes/ goals of care
Documents all interactions thoroughly and timely following established department standard work
Serves as the expert in system adult and child protection reporting policies
Collaborates with patients, families and interdisciplinary teams in developing an individualized discharge plan based on age, social and cultural considerations, clinical diagnoses, level of functioning and other relevant needs
Participates in hospital initiatives and projects to reduce length of stay and related barriers which may include collaborating with providers for clinical adjustments in care
Assists with ensuring the hospital is in regulatory compliance for care management related conditions of participation
Assists with efforts to improve patient flow in a high-capacity hospital setting
Works in a fast-paced hospital environment
Effectively re-prioritizes competing time sensitive job demands
Demonstrates the ability to advance evidence-based practice by utilizing standards, guidelines and pathways for care delivery
Incorporates data and information into practice to continually improve care and practice to enhance patient outcomes
Supports site and system quality initiatives
Provide age appropriate short- and long-term therapeutic interventions
If a licensed supervisor, provide clinical supervision as requested (site dependent)
Potential opportunity to facilitate a support group (site dependent)
Provides specialized psychosocial services across all phases of transplant care.
Conducts psychosocial transplant evaluations for transplant candidates
Identifies psychosocial strengths, barriers, and risk factors that may affect transplant candidacy or post-transplant success.
Develops recommendations and interventions to optimize transplant readiness.
Presents comprehensive psychosocial assessments during multidisciplinary transplant selection meetings.
Reassesses psychosocial status according to transplant program protocols.
Monitors changes in psychosocial functioning, support systems, behavioral health, financial concerns, and adherence.
Provides counseling and intervention throughout the waiting period.
Coordinates services to address newly identified barriers.
Provides assessment, counseling, discharge planning, and caregiver support during hospitalization.
Assists patients and families in adapting to medical and psychosocial changes following transplantation.
Collaborates with inpatient interdisciplinary teams to ensure safe transitions of care.
Provides ongoing psychosocial assessment and intervention as requested by patients or identified by the transplant team.
Supports adjustment to chronic illness, medication adherence, caregiver burden, return to work or school, financial concerns, mental health needs, and long-term quality of life.