Social Worker - Milwaukee, Oak Creek, Brookfield, Glendale, Racine, Kenosha

Concerto Renal Services is an industry leader in nursing home dialysis. We are a rapidly expanding business with a simple mission: reimagining dialysis care, one community at a time. Our model focuses on ensuring those with end-stage renal disease in a skilled nursing facility receive the best possible care through a more convenient, patient centric, continuous care model.

Summary/Objective

Concerto is seeking a Social Worker to join its team! The Social Worker provides psychosocial evaluation, adjustment counseling, quality of life support and empathetic care to patients who reside in a Skilled Nursing Facility or rehabilitation center regarding dialysis related issues. The Social Worker plays a vital role within the interdisciplinary team to incorporate psychosocial needs and concerns in planning care, educating, and follow through on a predetermined timeline with the regulations of CMS – Centers for Medicare and Medicaid Services. Meticulous documentation and goal setting to comply with company policies and to meet quality assessment performance indicators (QAPI). Reports directly to the market Team Lead and indirectly to the Director of Social Services.

PRIMARY DUTIES AND RESPONSIBILITIES:

• 
  Expected to model Concerto’s vision, mission, and values.
• Works with integrity and maintains effective relationships with professionalism and effective modes of communication.
• Conduct in person patient psychosocial assessments identifying areas of strength and areas of need that may impact their quality of life and dialysis outcomes.
• Each active patient requires an initial, 90 days, annual, and as needed unstable assessment and plan of care per CMS guidelines requiring effective time management skills and collaboration with the interdisciplinary team each month.
• On-going patient care and cadence of therapeutic interventions are built around patient needs to include documentation of progress and follow-up.
• Schedules and facilities monthly care plan meetings with the interdisciplinary team to include the patient or designee, physician, nurse, and dietitian to identify patient specific needs and effective interventions.
• Provide education and goal-oriented counseling relative to advance directives, transplant, dialysis modalities, and quality of life assessment outcomes.
• Proactively provides patients with education and therapeutic interventions to address treatment compliance and clinical outcomes concerns.
• At predetermined timelines social worker administers a quality-of-life assessment (KDQOL) and depression screens (PHQ-2/PHQ-9) and creates patient specific care plans to identified areas of needs.
• Completes quarterly patient assessments to identify any changes in needs or to reset goals since last assessment and document any intervention and/or follow-up notes in the patients’ electronic medical record.
• Participates in patient/family meetings to address any dialysis related concerns of either party.
• Create patient education packets and review upon admission.
• Utilizing a high level of organization and accuracy tracks monthly data of social work productivity and patient outcomes for monthly submission to team leads.
• Maintain professional working relationships with other staff of Concerto as well as in the skilled nursing facility.
• Takes initiative and action to respond to internal and external team and patient needs.
• Reports grievances to regional managers and social work team lead.
• Supports outpatient dialysis placement should a patient choose to leave the facility against medical advisement.
• Provide community resources and dialysis records for patients who discharge from the skilled nursing facility in collaboration with the facility social work team.
• Participate in administrative and staff programs as required, including attending staff meetings and in-service meetings.
• Compile and develop educational materials to be used as teaching aids in education of patients and staff as needed.
• Supports the opening of new clinics to include admissions of existing dialysis residents.
• Understands and commits to Concertos policies and procedures.
• Collaborates with Concertos EQRS specialists to assist with obtaining required patient documentation to support the need for on-going dialysis in the community.
• Special projects as needed.

QUALIFICATIONS:

• Master’s degree in social work.
• Healthcare or dialysis related background preferred.
• Must hold a valid state license; clinical not required.
• Unencumbered driver’s license.
• Intermediate computer skills and proficiency with MS Word, Excel, Outlook as well as becoming proficient with Concerto specific applications within 60 days of employment.

Physical Demands of the Job

• Must be able lift at least 20 lbs.
• Requires mental, visual, and auditory attention to patients, customers and staff.
• Work environment is characteristic of a health care facility with air temperature control and moderate noise levels.
• May be exposed to infectious and contagious disease/materials.
• Requires travel between facilities.

Other Duties

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. I have reviewed the job description and understand the responsibilities of this position.