Provides guidance, psychosocial assessments, support, short term counseling, and information to patients and their families to maximize their overall psychosocial functioning and adjustment to dialysis and alternate lifestyle. Advise and provide resources regarding financial programs, medication assistance programs, vocational rehabilitation programs, transportation resources, mental health and substance abuse resources, and home health/homemaking agencies. Provide short term counseling and treatment planning to meet the immediate emotional needs of patients with renal disease to include the following interventions: CBT, SFBT, DBT, Acceptance & Commitment Therapy, Motivational interviewing, visualization techniques, and mindfulness exercises. Coordinate with hospital physicians and social workers to determine discharge needs for patients who are hospitalized. Maintain working knowledge of government and private insurance options. Maintain working knowledge of mental health, substance abuse and community resources. Network with community providers to create and ensure proper resource connections. Modality educator and IDT team meeting facilitator/leader responsible for discussing and reviewing clinic metrics, grievances, focus patients, clinical and psychosocial needs. Participate in quality improvement and root cause analysis to support and grow transplant metrics.

Participates in interdisciplinary meetings and patient care management while implementing an interdisciplinary approach to assess, coordinate, and implement a timely and safe discharge while focusing on DRG. Provides brief emotional and psychosocial supportive counseling to patients and families which requires working knowledge of mental health and substance abuse disorders, developmental disabilities, chronic/acute diagnosis, and medical terminology. Maintain working knowledge of insurance plans and qualifications for SNF placement. Review clinical records provided by providers to determine medical necessity and appropriateness of care for discharge and or SNF placement. Subsequently, working with the patient’s insurance companies and utilization review case manager to determine if prior auth was obtained. Duties also include biopsychosocial assessments and developing plans of care. These duties include but are not limited to sub-acute/ acute rehab placement, inpatient/ home hospice placement, home health/infusion linkage, durable medical equipment, ongoing assessment of patients and family’s needs for post-acute care and placement, transitions of care activities, advance directive planning, post discharge follow up appointments, pharmaceutical applications, and referrals to community resources.

Participates in interdisciplinary meetings and patient care management while implementing an interdisciplinary approach to assess, coordinate, and implement a timely and safe discharge in coordination with DRG. Provides brief emotional and psychosocial supportive counseling to patients and families which requires working knowledge of mental health and substance abuse disorders, developmental disabilities, chronic/acute diagnosis, and medical terminology. Review clinical records provided by providers to determine medical necessity and appropriateness of care for discharge and or SNF placement. Subsequently, initiate insurance authorization to insurance companies to ensure prior approval for SNF placement while working collaboratively with utilization review case manager. Initiate home health, DME, and infusion orders. Duties include but are not limited to sub-acute/ acute rehab placement, inpatient/ home hospice placement, home health/infusion linkage, durable medical equipment, ongoing assessment of patients and family’s needs for post-acute care and placement, transitions of care activities, advance directive planning, post discharge follow up appointments, pharmaceutical applications, and educating patients and families of available resources in the community.

Provide direct service coordination and support to members living with HIV/AIDS while maintaining a case load of 75+ or more. Conduct initial and ongoing psychosocial assessments with interdisciplinary team while creating Individual Service Plans (ISP). This also includes advocating on the member’s behalf to decrease or eliminate barriers to care while providing HIV education, ongoing adherence to medications, housing assistance, community referrals, HIV testing, prevention counseling, mental health and substance abuse resources, and harm reduction counseling.

Provide individual/group therapy and crisis management to individuals dealing with mental health, substance, abuse and emotional disorders in collaboration with twelve step drug court program while implementing evidence-based methods such as cognitive behavior therapy and motivational interviewing techniques as well as completing intakes and assessments. As an intern, I also had the pleasure of working with clients using Seeking Safety and Moral Reconation Therapy under the supervision of fellow counselors.

Provide in home intervention services to children & adolescents with behavior or developmental challenges in the community. Such interventions include parenting, behavior aid, crisis intervention planning, and community referrals according to need. Duties also include but are not limited to providing housing assistance, community referrals, and ongoing assessment of individual’s strength and limitations to care.

Assist Oncology social worker with complex discharges and discuss supportive care treatment options such as hospice, resources, rehab, or home health. Assist patients with advance directives in conjunction with pastoral care. Provide support groups/connections and resources to patients and families in need. Attend and facilitate family team meetings along with interdisciplinary team. Provide support and education to patients while utilizing strengths perspective, afrocentric perspective, and motivational interviewing techniques.

Provide holistic and comprehensive case management services to children ages 0-21 years of age and adults including: intake assessment, benefit assessment, goal setting, long-term care plan development, court appearances, weekly case plan development, assessing reunification progress monitoring, money management, housing assistance, advocacy, children/home evaluations, and referrals. This also includes providing support to children and adults who are experiencing neglect, physical and sexual abuse, poverty, domestic violence, medical neglect, and or mental health challenges. Case managers also have to commit to court appearances to testify as to the level of risk experienced by children to remain in the state’s legal custody. Specialists also assist teenagers ages 14-21 with independent living services that provides life skills and college preparation for youth.