Social Worker MSW | Kidney Transplant

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Pay Range:

The pay range for this position is listed below. Actual pay rate dependent upon experience.

Position Highlights

1. Psychosocial evaluation:  Interviews transplant recipient candidates and family members to obtain information about home environment, family systems, health history, and patient’s personality traits. Assess transplant psychosocial candidacy according to psychosocial principles and department protocol, and document and provide recommendations to the Review and Selection Committee (as assigned to the pre-transplant phase).  Collaborate with the transplant Psychologist as needed for psychosocial assessment and recommendations.
Assesses patients’ ability to adhere to therapeutic regimens; Assesses patient’s and living donor’s (if applicable) coping abilities and strategies;  Assesses patient’s financial capabilities and resources, including who will pay for post-discharge medical care for the donor, (as applicable); and Provision of adequate social, personal, housing and environmental support.  Assesses patient’s mental health history, including degree of substance and alcohol use (and history of evaluation, treatment, referral and/or monitoring) and how it may impact the success or failure of organ transplantation or the donor’s mental health post-transplant;

2. Evaluates data gathered in terms of the medical plan of treatment, available social service programs, and develop a plan that advocates for, and will provide maximum benefits and safety for each patient during evaluation, listing, transplant inpatient, and post-transplant phases.  Utilizes community services and other resources to assist patients to resume life in the community following transplantation, providing referrals as needed (including vocational rehabilitation or housing referrals, as applicable):  substance abuse evaluation, treatment and referral and monitoring; individual counseling; crisis intervention; death, dying and bereavement counseling.  Coordinates with dialysis Social Worker during pre-transplant phases.

3. Attends inpatient rounds and serves as the multidisciplinary transplant discharge meeting/patient care conference facilitator for transplant (as assigned to post-transplant phase). Participates in the initial assessment, care planning, intervention, reassessment, and discharge planning, based on the needs of the transplant patient or living donor (as assigned).  Serves as a liaison to provide continuity of care for transplant recipients between inpatient and outpatient phases of care.

4. Assists patients and families to understand, accept, and follow medical recommendations with emphasis on assisting patient to adhere to the prescribed medical regimen.

5. Provides individual and group counseling.  Provides crisis intervention or appropriate referrals, if applicable. Utilizes community and other resources to assist patients to resume life in the community following transplantation, providing referrals as needed: substance abuse evaluation, treatment and referral and monitoring; individual counseling; crisis intervention; death, dying and bereavement counseling.  Coordinate with dialysis Social Worker during pre-transplant phases.

6. Completes, prepare and maintain transplant forms and documentation for the patient record adequately that other transplant team members are able to coordinate care.  Monitor and resolve open actions by utilizing transplant software.

7. Provides patient and family education as needed, in conjunction with Transplant Coordinators, and Financial Coordinator. Works collaboratively with the transplant team to provide coordinated services, which facilitates continuity of care for the patients, providing patient advocacy. Receive report regularly from the Financial Coordinator in order to adequately counsel patients regarding transplant benefit and coverage considerations.  Coordinates support group activity and patient and family educational newsletters and communications.

8. Maintains ongoing knowledge of Social Services regulations and resources.
Serves as the social work representative on the multidisciplinary transplant team providing input for programming and projects, procedure development, process improvement, meetings and committees concerning organ donation awareness initiatives, transplant recipient support groups, patient education, and collaborative participation with community advocacy groups, such as the National Kidney Foundation. 

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

• Interviews patient and family members to obtain information about home environment, family systems, health history, and patient’s personality traits.
• Evaluates data gathered in terms of the medical plan of treatment, available social service programs, financial counseling and plan a pertinent therapy program that will provide maximum benefits and safety for each patient.
• Assists patients and families to understand, accept, and follow medical recommendations with emphasis on assisting patient to be medically compliant with care plan.
• Performs a variety of services such as advising on social problems, arranging for discharge or post-operative care at home, assisting patients/families needing placement into assisted living or nursing homes, arranges for transportation to appointments and treatments, and works to alleviate anxiety and fears of patients and family members.
• Conducts supportive visits by interviewing patients and their family members to obtain information regarding their response to their diagnosis including evaluation of strengths, coping skills, supports, characteristics of family, health history and personality traits. Prepares and maintains patient documentation in EMR.
• Maintains department policies, procedures, objectives, and quality assurance program, safety, infection and environmental control.
• Assists with data collection, analysis and reporting as required by the hospital, administrative council, care teams, JCAHO, and other agencies.
• Conducts individual, marital, family and group therapies as necessary. Coordinate care conferences as needed. Serves as the social work representative in multi-disciplinary team approach to patient care.
• Utilizes research findings to improve outcomes and support, and provide quality of life for patients and their families. Works collaboratively with Case Management in providing coordinated services, which facilitates continuity of care for our patients.
• Works with emotional problems including but not limited to assisting patients, residents and families with anxieties and stress caused by illness, admission to hospital/nursing home, crisis situations, difficulties in coping with physical disabilities, fears related to helplessness and death, the need for nursing home/assisted living/specialized care, and providing educational materials.

• Master's in Social Work from an accredited program
• Social Worker - Licensing Board An active license in the state of practice Upon Hire

• Qualified Mental Health Provider (QMHP) - Licensing Board active in the state of practice Upon Hire
• 1-3 years

• Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community.
• Promote Avera’s values of compassion, hospitality, and stewardship.
• Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future.

• PTO available day 1 for eligible hires.

• Free health insurance options, for full-time single coverage on Avera High Deductible Health Plan

• Up to 5% employer matching contribution for retirement

• Career development guided by hands-on training and mentorship

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to talent@avera.org.