Social Worker Clinical Specialist

5 days ago

Baltimore, Maryland, United States Fresenius Medical Care Full time
Job Description

This role is an entry-level position for a Master's level Social Worker. The primary function of this position is to provide psychosocial services to patients treated by Fresenius Medical Care, including in-center and home dialysis patients (if applicable), utilizing Social Work Theory of Human Behavior and accepted methods of social work practice.

The Social Worker will work with the healthcare team to promote positive adjustment, rehabilitation, and improved quality of life for our patients. In collaboration with the interdisciplinary team, the Social Worker will inform, educate, and support staff in understanding the emotional, psychological, and behavioral impact of Chronic Kidney Disease on the patient and family to ensure comprehensive quality care of our patients.

Main Responsibilities
  • Patient Assessment/Care Planning/Counseling
    • The Social Worker assesses patients' psychosocial status, strengths, and areas of need that may affect rehabilitation and optimal treatment outcomes as part of the comprehensive patient assessment.
    • The Social Worker participates in care planning in collaboration with the patient and healthcare team to identify effective interventions that will help the patient meet rehabilitation, treatment goals, and improve quality of life.
    • The Social Worker utilizes Fresenius Medical Care patient education programs, established social work theory and methods, social work-focused interventions, and quality of life measurement instruments as part of assessment and care planning to address barriers and meet patient treatment goals.
    • The Social Worker provides monitoring and interventions for the patient to adjust to dialysis and achieve optimal psychosocial status and quality of life.
    • The Social Worker provides supportive counseling services to patients as permitted within the scope of their clinical training and state license.
    • The Social Worker provides educational and goal-directed counseling to patients who are seeking transplant.
    • The Social Worker provides information and assists the team and patient with referral to community resources (home health services, vocational rehabilitation, etc.) to facilitate optimal treatment outcomes.
    • The Social Worker maintains current knowledge regarding local vocational/educational rehabilitation programs and assists patients with referral and access to vocational rehabilitation to enable them to remain employed, become employed, or receive education.
    • The Social Worker assesses patient awareness of advance directives; assists with accessing advance directive forms/information and facilitates discussion of advance directive wishes, if necessary, with the healthcare team and the patient's family/support persons.
    • In collaboration with the physician and nurse, the Social Worker participates in the discussion of patient DNR status in the facility to ensure patient and/or family understand and make an informed decision about their care.
    • The Social Worker knowledgeable of and adheres to Fresenius Medical Care Social Work Policy and Measuring Patient Physical and Mental Function Policy, including documentation.
    • The Social Worker documents based on MSW interaction and interventions provided to patient and/or family.
  • Quality
    • The Social Worker provides psychosocial support and/or Social Work Focused Interventions to address non-adherence, quality outcome, and quality of life concerns for all patients based on acuity level.
    • The Social Worker participates in monthly Quality review meetings with the interdisciplinary team. Reports on quality indicators related to adherence, such as Missed and Shortened Treatments, Quality of Life Trends, and Service Recovery.
  • Patient Education
    • The Social Worker assesses patient knowledge of kidney disease for barriers that may affect adherence to treatment. Works with patient, family, and healthcare team to provide education tailored to the patient's learning style, communication barriers, and needs.
    • The Social Worker, with other members of the interdisciplinary team, provides appropriate information about all treatment modalities.
    • The Social Worker facilitates the transplant referral process and collaborates with interdisciplinary team on transplant waitlist management.
    • The Social Worker provides ongoing education to patient/family regarding psychosocial issues related to End Stage Renal Disease (ESRD) and all support services that are available.
    • The Social Worker reviews patient rights and responsibilities, grievance information (company and network) and other facilities policies with patient and/or the patient's representative to ensure patients' understanding of the rights and expectations of them.
    • The Social Worker collaborates with the team on appropriate QAI activities.
  • Patient Admission and Continuity of Care
    • The Social Worker reviews Patient Rights and Responsibilities, Grievance Procedure & Important Numbers Handout, FKC Non-discrimination policy, DNR Statement (if applicable) and address any immediate needs/concerns.
    • The Social Worker understands the referral and admission process and supports the clinic in regard to the patient needs for scheduling to maximize adherence and adjustment.
    • The Social Worker will interview the patient to identify root causes or concerns for the discharge request, (i.e. transfer to hospice, relocation, dissatisfaction with services or staff) and share causes/concerns with operational leadership.
  • Insurance and Financial Assistance
    • The Social Worker collaborates and functions as a liaison for patient with Insurance Coordinators to address issues related to insurance.
    • In collaboration with Insurance Coordinators, the Social Worker provides information and education to patients about payment to dialysis (federal, state, commercial insurance, state renal programs, AKF HIPP, and entitlement programs).
    • The Social Worker collaborates with the Insurance Coordinator of any changes to patient state that impacts insurance i.e. transplantation, discharged, loss of coverage, or extended travel.
    • The Social Worker refers patients to patient billing solutions (PBS) department for questions/concerns in regard to treatment-related bills.
  • Staff Related
    • The Social Worker assists with interview process and decision to hire new personnel if requested by SW Manager/Senior Manager.
    • The Social Worker works with the administrative support staff to maintain updated patient resource lists (e.g. maintain updated list of transportation resources).
    • The Social Worker provides training to staff pertaining to psychosocial topics as needed.
    • The Social Worker contributes and participates with weekly team huddles. Discusses any urgent patient issues with staff.
  • The Social Worker adheres to work-defined caseload guidelines based on state regulatory requirements.
  • The Social Worker performs other related duties as assigned.

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