Clinical Consultant Social Worker (MSW/LSW) - Renal Transplant

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Job Description Summary:

This position will support end stage renal patients including renal transplant candidates through successful transplant.

This candidate should have experience with ESRD and/or Transplant Patient Care.

In this role, the social worker will be responsible for the following but not limited to this list:
Complete psychosocial assessment for selection of a candidate for organ transplant.
Conduct psychosocial assessment and interventions and makes treatment recommendations and engages patients/families in adherence to the treatment plan by reducing or eliminating, to the extent possible, the social, psychological, financial, behavioral, and regulatory barriers to successful medical outcomes.
Deal with families exhibiting complex family dynamics.
Communicate with interdisciplinary team regarding the discharge planning status of all patients referred by them.
Educate patients/family and physician regarding post-acute options and address freedom of choice and financial concerns.
Participate in discharge planning for assigned patients to ensure a timely discharge and provide appropriate linkage with post-discharge care providers and resources.
Serve as a resource person and provides counseling and intervention related to treatment decisions and end-of-life issues.

Responsibilities And Duties:

30% Clinical Assessment
Conducts patient/family/significant other interviews, chart reviews, and professional collaboration to obtain and interpret information pertaining to patient/client biopsychosocial functioning. Assessment to include, but not be limited to: developmental and age-specific needs; ability to care for self; ability to care for dependents; ability to meet basic custodial and financial needs; ability to engage in meaningful social and emotional relationships; and ability to comprehend and comply with treatment recommendations. Develops care plan, including discharge plan, incorporating medical plan of care. Participates in identification of cases of abuse, neglect or exploitation and refers such cases to the legally mandated authorities when applicable.  Provides crisis intervention, information and referral and linkage to community resources as needed.

30% Intervention Management
Develops a plan of intervention based upon assessment to resolve identified problems and/or to support and enhance biopsychosocial functioning.  Through individual, family, or group modalities, employs clinical intervention skills including, but not limited to, treatment planning; continuum of care planning (including discharge planning); supportive counseling; crisis intervention; specialized problem oriented planning and intervention; and educational counseling.

25% Population Management
Staff is accountable for coordinating clinical and financial outcomes of an assigned population.  Works collaboratively with interdisciplinary staff and external organizations to achieve timely, cost effective management of patient care.  Monitors for quality and type of services delivered to patients, ensuring management within established parameters. Functions as a liaison to the payer to manage the post-discharge financial resources and ensure expected treatment process, progress and discharge plan. Monitors and ensures completeness of all assigned patients in areas of treatment plan and timely reports. 

10% Documentation and Regulatory Compliance
Thoroughly documents assessments and interventions in patient’s medical record and information systems in accordance with department standards. Complies with internal and external documentation requirements as related to specific patient/system needs and regulatory requirements.

5%
Maintains awareness of current hospital, community services and appropriate care options that can assist patient/clinical biopsychosocial functioning. Provides information as well as facilitates successful linkages between those services and the patient/client.  Performs additional functions as may be appropriate to the position.