Caseworker Home Care

Dialysis Inpatient/Outpatient Social Worker, Must be a LMSW

This role is in Far Rockaway, NY

Report to : Director of Social Work

Responsibilities:

Dialysis social workers assist kidney failure patients with the emotional, financial, and lifestyle adjustments necessary during treatment, including mental health support, insurance navigation, and transplant referrals. They play a critical role in patient care by managing both the psychosocial and practical aspects of dialysis management.

Under the supervision of the Director, the Social Worker performs a variety of service required under the regulations of ESRD regulations, with the main focus of providing psychosocial support, and implementing appropriate interventions such as linkage to community resources, homecare services and any other identified needs. The Social Worker Must be able to provide the following:

Comprehensive assessments to include identification of mental health issues, social determinate of health, or any identification of abuse or neglect

Follow-up with the high-risk patients and/or families post discharge to assess individual needs/interventions that was implemented prior to discharge.

Patient Dialysis scheduling per policy and procedures

Work collaboratively with the homecare nurse with new referrals and follow-ups post discharge

Make appropriate referrals to public benefits including referrals for health insurance coverage

Assist in completing the required paperwork in order for patient to access care in the community

Assist in planning, arranging, and implementing Transportation mental health clinics or social programs

Providing brief counseling to chronically ill patients either to individuals or family settings.

Uses a variety of techniques to assist in the resolution of patient care related problems.

Providing Crisis interventions to patient/caregivers whenever incident arises

Help to organize treatment plan and follow re-admission pathway in an effort to prevent frequent ED use and hospital re-admission.

Provide educational materials as needed or required information on Transplant Education and Referrals

Coordinating Transient/ Travel plans for patients

Provide reports and monthly statistics

Documenting Patient Status Notes and Level Changes

Medicare and Medicaid referrals/ Re-certifications

Assume other responsibilities as directed

Requirements :

License by the State of New York for LMSW

Dialysis experience preferred

Experience in an ambulatory health center preferred

Must be able to problem solve and apply critical thinking skills during crisis situations

Must be computer literate; familiar with Microsoft word and Excel.

Must be highly organized, work with the interdisciplinary team

Home visits/Community visits required whenever warranted

Day shifts with 1 per month Day late shift to cover 4th shift in the outpatient HD unit.

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