As a Licensed Clinical Social Worker you will assess, educate and collaborate with patients on care planning that addresses everything from work, travel and financial concerns to emotional support. Provide individuals, families, and groups with the psychosocial support needed to cope with chronic, acute, or terminal illnesses. Services include advising patients and/or family/caregivers, providing patient education and counseling, and making referrals for other services. The Social Worker may also provide care and case management, or interventions designed to promote health, prevent disease, and address barriers to access to healthcare.
- 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.
- Assesses patient knowledge of kidney disease for barriers that may affect adherence to treatment.
- Assess for social determinants of health that may impact treatment and assist with identifying community resources to address needs.
- Assist patient and/or family/caregiver in completing applications for services and/or resources.
- Provides ongoing education to patient/family regarding psychosocial issues related to Chronic Kidney Disease (CKD) and End Stage Renal Disease (ESRD) and all support services that are available.
- Enables support groups and family members in dealing with and understanding the needs of the patient.
- Develops detailed and error-free case notes involving mental health and risk assessments.
- Adjusts treatment plans in compliance with changes in the status of the patient.
- Provides information and assists the team and patient with referral to community resources (home health services, vocational rehabilitation, etc.) to facilitate optimal treatment outcomes.
- Provides supportive and goal directed counseling to patients who are seeking transplant.
- 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, participates in the discussion of patient DNR status in the facility to ensure patient understanding and informed decision making.
- Utilize motivational interview techniques to address non-adherence and quality of life concerns for all patients.
- Collaborates with Facility Management and Accounting/Billing to address patient issues related to insurance or copay concerns.
- Conduct in-home and face to face visits as necessary to assess patient needs and implement plan of care (up to 50% same day travel with this role).
- Perform other duties as assigned
- Works and communicates well in a team environment.
- Displays ethical conduct at all times toward patients, families, and co-workers.
- Completes training as required and demonstrates professional effectiveness and positive demeanor.
- Maintains a customer/client focus.
Required Education and Experience:
- Masters degree in social work.
- Active and unrestricted state-specific licensure required; Licensed Clinical Social Worker
- Unrestricted drivers license and reliable transportation (role has up to 50% same day travel to conduct face to face visits with clients)
- Excellent communication skills; ability to communicate clearly and concisely both orally and in writing to patients, family members and various professionals.
- Basic computer skills and understanding.
Preferred Education and Experience
- Five (5) years of related work experience.
- Two (2) years of experience working with the dialysis/kidney care population.
- Track record of excellent customer service skills.
- Medicare or Medicaid experience preferred
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
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