Master Social Worker Transplant Services

Master Social Worker

Bring your expertise and compassion to our Transplant Services team as a Master Social Worker. In this dynamic role, you'll provide direct patient support in ambulatory clinic settings, guiding individuals and families through complex transplant journeys. You'll also play a key role behind the scenes with care coordination, phone outreach, and detailed charting to ensure seamless transitions. For liver transplant patients, you'll participate in inpatient coverage rotations, supporting fresh transplants and readmissions.

Enjoy a consistent weekday schedule—Monday through Friday, 7:30 AM to 4:30 PM—with the flexibility to transition to 4x10s or 9x9s after orientation. If you're passionate about making a meaningful impact and thrive in a collaborative, fast-paced environment, this is your opportunity to join a team that changes lives every day.

University Medical Center Phoenix is a nationally recognized academic medical center. The world-class hospital is focused on coordinated clinical care, expanded research activities and nurturing future generations of highly trained medical professionals. Our commitment to nursing excellence has enabled us to achieve Magnet™ recognition by the American Nurses Credentialing Center. The Phoenix campus, long known for excellent patient care, has over 730 licensed beds, several unique specialty units and is the new home for medical discoveries, thanks to our collaboration with the University of Arizona College of Medicine - Phoenix. Additionally, the campus responsibilities include fully integrated multi-specialty and sub-specialty clinics.

POSITION SUMMARY

This position provides comprehensive care coordination for families and patients, supporting a holistic and coordinated approach across the continuum of care from transplant referral through life long post-transplant care. Provides thorough, advanced clinical psychosocial evaluations and ethical decision-making to formulate recommendations or goals required for transplant listing. Assists with chronic disease management of end-state organ disease/failure and provides increased supportive care to the patient, family, and caregiver. Collaborates with a multidisciplinary team to facilitate timely treatment and increased supportive care throughout the patient/family experience. Assists patients, families, and caregivers with identifying and overcoming barriers which may hinder quality medical and psychosocial patient care. Collaborates with financial counselor, inpatient social work services and transplant multidisciplinary team members in clinical settings, patient conferences, and program meetings. The provision of these services in the United States is mandated by the Centers of Medicare and Medicaid Services (CMS) for Medicare-approved transplant centers.

CORE FUNCTIONS

1. Processes and facilitates the assessment of the patient with analysis of functional and psychological needs within the framework of his/her developmental stage, functional abilities, cultural milieu, and support network. Assessment includes initial Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) and/or Psychosocial assessments, behavioral observations, evidence-based mental health and substance use screenings, resource identification, collection and analysis of information to determine the patient, caregiver, and donor's individualized plan of care and treatment needs in accordance with Organ Procurement and Transplantation Network (OPTN) policy. Documents all interventions in the patient medical record both timely and accurately.

2. Evaluates functional, cognitive, and emotional abilities and limitations of patients, families, and caregivers to determine appropriate intervention as needed. Develops treatment goals that are functional, measurable, patient-centric, and reflect key limiting factors. Collaborates with the multidisciplinary team during patient hospitalization to ensure safe discharge planning and continuity of care in outpatient transplant clinic settings optimizing the best outcomes of the transplant recipient.

3. Works collaboratively with the financial counselor when health benefit gaps are identified by facilitating identification and pursuit of health benefits supplemental programs for medication coverage and assistance with out-of-pocket expenses.

4. Develops, implements, monitors, and documents the utilization of resources and progress of the patient through their transplant journey. Facilitates options and services to meet patient's health care needs through a continuous assessment and verification of patient's plan of care using an interdisciplinary holistic approach. Provides medical, legal, social, financial, and community referrals and consultations as appropriate and in coordination with physicians and other team members. Assists, facilitates, and provides education around the completion of patient health care directives.

5. Attends and participates in daily inpatient transplant multidisciplinary team rounds, weekly transplant outpatient rounds, patient pre-transplant selection committee meetings, and transplant quality assessment and performance Improvement (QAPI) meetings.

6. Oversees process improvement activities for populations of transplant patients to achieve optimal clinical, financial, operational, and satisfaction outcomes. Participates in staff development to maintain current standards of practice and ensure the highest quality of care. Understands and complies with guidelines defined by CMS and/or United Network of Organ Sharing (UNOS). Utilizes knowledge related to government/community resources including Medicare, Medicaid, long-term care, and other applicable resources/services.

7. Ensures that patient, family, and caregivers understand end stage organ processes. Recommends actions and provides information in coordination with the multidisciplinary team. Provides encouragement and emotional support to patients, family, and caregivers during various stages of the transplant process which may include family care conferences and end of life discussions.

8. Advocates for quality of life and stability through supportive counseling. Provides crisis intervention and connection to community resources to patients, families, and caregivers. May facilitate transplant-sponsored support groups for patients, families, and caregivers.

9. Works autonomously to define best practices to optimize patient care. Confers with supervisor on any unusual situations. Internal customers: All levels of staff, including physicians. External Customers: Patients, families, caregivers, employees of other healthcare institutions, physician offices, referring physicians, community providers and agencies, payers, provider networks, and regulatory agencies.

MINIMUM QUALIFICATIONS

Requires a Master's Degree in Social Work, Counseling or related field. Requires a Licensed Master Social Worker (LMSW) (equivalent*) or Licensed Clinical Social Worker (LCSW). An equivalent license applies to states that do not recognize an LMSW; therefore, the employee must possess a Master's Degree and be a Licensed Social Worker. For assignments in an acute care setting, Basic Life Support (BLS) certification is required. Requires a proficiency level typically achieved with 5 years acute care hospital experience. Banner Registry and Travel positions require a minimum of one year experience in an acute care hospital setting. Experience must include working in an acute care setting within the past 12 months as a Social Worker MSW in the specialty area. Must have knowledge of government/community resources such as Medicare, Medicaid, long-term care, or any other applicable resources/services. Must demonstrate critical thinking skills, problem-solving abilities, effective communication skills, human relations skills, and time management skills. In acute care, must be able to work flexible hours and take rotating call after hours.

Must maintain knowledge of available community resources and services.

Strong decision-making skills and problem-solving skills are required.

PREFERRED QUALIFICATIONS

Additional related education and/or experience preferred.