Acute Social Worker Adult Kidney Transplant

Job Overview

Fairview is looking to hire a Licensed Independent Clinical Social Worker (LICSW) to join our Adult Kidney Transplant team. This is a 0.8 FTE, benefit-eligible position, approved for 64 hours every two weeks. This role does require that you are able to work every 6th weekend. 

As a member of the Solid Organ Transplant interdisciplinary team, the Social Worker provides comprehensive psychosocial services and interventions to transplant candidates, recipients, living donors, families, and caregivers. This role supports patients and their support systems throughout the entire transplant journey, helping them strengthen coping skills, navigate complex psychosocial needs, and maintain effective social functioning.

Consistent with CMS Conditions of Participation for Transplant Programs, social work services are provided throughout all phases of transplant care, including pre-transplant evaluation, waitlist management, inpatient hospitalization, transplantation, discharge planning, post-transplant follow-up, and long-term outpatient care.

The ideal candidate will bring strong clinical social work skills, excellent communication and collaboration abilities, and an interest in supporting patients and families through the complex medical, emotional, and psychosocial aspects of kidney transplantation.

The Social Worker has primary responsibility for evaluating the psychosocial status and needs of transplant candidates, families, and recipients in both inpatient and outpatient settings. They provide ongoing consultation, counseling, education, advocacy, resource coordination, and crisis intervention throughout the transplant continuum. The Social Worker collaborates closely with physicians, advanced practice providers, nurses, pharmacists, psychologists, financial coordinators, and other members of the interdisciplinary transplant team to optimize patient outcomes and ensure compliance with regulatory and accreditation standards.

This individual practices independently within the scope of their licensure and professional standards, assumes leadership in patient care and program development, participates in quality improvement initiatives, and requires minimal supervisory guidance.

Responsibilities

• Attends daily in person interdisciplinary care team rounds
• Conducts thorough psychosocial assessments with patients and/ or their surrogate decision makers
• Helps the care team navigate and mediate complex psychosocial dynamics
• Is well versed in the surrogate decision maker policy and assists care team members with identifying surrogate decision makers according to the policy
• Communicates frequently with the interdisciplinary team to ensure continuity and effective coordination of care
• Provides emotional support and counseling surrounding adjustment to sudden illness, grief/bereavement and end of life planning
• Addresses social determinants of health and assists with connecting patients to needed resources in the community such as chemical dependency treatment, domestic violence resources, housing stabilization services, mental health services, food shelves, transportation, financial assistance etc.
• Arranges and facilitates in person care conferences as needed to support patients and their families surrounding navigating complex medical decision-making processes/ goals of care
• Documents all interactions thoroughly and timely following established department standard work
• Serves as the expert in system adult and child protection reporting policies
• Collaborates with patients, families and interdisciplinary teams in developing an individualized discharge plan based on age, social and cultural considerations, clinical diagnoses, level of functioning and other relevant needs
• Participates in hospital initiatives and projects to reduce length of stay and related barriers which may include collaborating with providers for clinical adjustments in care
• Assists with ensuring the hospital is in regulatory compliance for care management related conditions of participation
• Assists with efforts to improve patient flow in a high-capacity hospital setting
• Works in a fast-paced hospital environment
• Effectively re-prioritizes competing time sensitive job demands
• Demonstrates the ability to advance evidence-based practice by utilizing standards, guidelines and pathways for care delivery
• Incorporates data and information into practice to continually improve care and practice to enhance patient outcomes
• Supports site and system quality initiatives
• Provide age appropriate short- and long-term therapeutic interventions
• If a licensed supervisor, provide clinical supervision as requested (site dependent)
• Potential opportunity to facilitate a support group (site dependent)

Transplant-Specific Responsibilities:

Provides specialized psychosocial services across all phases of transplant care. Responsibilities include:

• Conducts psychosocial transplant evaluations for transplant candidates
• Identifies psychosocial strengths, barriers, and risk factors that may affect transplant candidacy or post-transplant success.
• Develops recommendations and interventions to optimize transplant readiness.
• Presents comprehensive psychosocial assessments during multidisciplinary transplant selection meetings.
• Reassesses psychosocial status according to transplant program protocols.
• Monitors changes in psychosocial functioning, support systems, behavioral health, financial concerns, and adherence.
• Provides counseling and intervention throughout the waiting period.
• Coordinates services to address newly identified barriers.
• Provides assessment, counseling, discharge planning, and caregiver support during hospitalization.
• Assists patients and families in adapting to medical and psychosocial changes following transplantation.
• Collaborates with inpatient interdisciplinary teams to ensure safe transitions of care.
• Provides ongoing psychosocial assessment and intervention as requested by patients or identified by the transplant team.
• Supports adjustment to chronic illness, medication adherence, caregiver burden, return to work or school, financial concerns, mental health needs, and long-term quality of life.

Required Qualifications

• Master of Social Work
• 1 year Experience working in a healthcare or related setting
• LICSW Mstrs Deg Clinical or Provisional LICSW State of Minnesota Upon Hire

Preferred Qualifications

• 3 years Experience working in a healthcare or related setting

Benefit Overview

Fairview offers a generous benefit package including but not limited to medical, dental, vision plans, life insurance, short-term and long-term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! Please follow this link foradditional information: https://www.fairview.org/careers/benefits/noncontract

Compensation Disclaimer

The posted pay range is for a 40-hour workweek (1.0 FTE). The actual rate of pay offered within this range may depend on several factors, such as FTE, skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization values pay equity and considers the internal equity of our team when making any offer. Hiring at the maximum of the range is not typical. If your role is eligible for a sign-on bonus, the bonus program that is approved and in place at the time of offer, is what will be honored.
EEO Statement

EEO/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status