Full-time Social Worker for ESRD population, managing a caseload of approximately 100 patients. Responsible to complete psychosocial assessments, participated in monthly interdisiciplinary rounds and assessments on each patient, provided supportive counseling, informal groupwork, crisis intervention, behavioral management. education. Participated in monthly Quality Assurance Performance Improvement activities and initiatives. Facilitated Patient/Family/Team meetings. Linked patients/families to appropriate community resources. Arranged transportation to and from treatment, and other medical appointments. Arranged transient dialysis for travelling patients.Maintained patient information and documentation in CROWNWeb Data System. Worked collaboratively with other providers involved in patient's care to maximize support, independent functioning, and overall safety and well-being. Significant telephonic support and assistance to family members. Liaisoned with Transplant Centers, Social Workers and Nurse Coordinators to facilitate Transplant evaluation process, update patient status and continued candidacy for Transplant. Facilitated understanding and completion of Advance Directives. Maintained contracts with skilled nursing facility providers.

Provided Social Work services to patients in all units including Hematology-Oncology, Neurology, Cardiology, Medical-Surgical, Orthopedics, Medical-Surgical ICU, Cardiothoracic ICU Stepdown ICU, Inpatient Dialysis, inclusive of Hemo and PD, Mother/Baby, Pediatrics, Emergency Department, and Outpatient Medical Clinic. Responsibilities included psychosocial assessments, counseling, crisis intervention, arranging and facilitating patient/family/interdisciplinary team meetings, discharge planning, educating patients, families, and staff. Participated in Care Coordination Department meetings, activities, and Quality Improvement initiatives. Collaborated with Healthcare Professionals to maximize and ensure quality outcomes for patients and families.

Served as Social Worker in acute hospital setting as well as subacute rehabilitation unit within the hospital. Completed psychosocial assessments, provided support, crisis intervention, education,and resources. Implemented safe and timely discharge plans from the acute hospital as well as the subacute unit. Ensured that all documentation was completed expediently. Completed MDS and Care Plans. Attended weekly care planning meetings as a key member of the Interdisciplinary team. Identified and addressed patients issues and or concerns as related to the plan of care. Served as Oncology Social Worker, and provided Social Work services to ICU. Provided coverage for Preadmission Screening Unit to assess surgical patients to identify discharge goals, potential barriers to discharge.

Medical Social Workeer for patient population with severe chronic, and terminal illness. Served a large population of Oncology, Neurology, Cardiology, Trauma, Mental Illness, Developmental Disabilities, and Autoimmune diseases, inclusive of HIV/AIDS. Additionally responsible for case management/social work for a 20 bed Transitional Care Unit. established long term relationships with patients/families, providing extensive counseling, griefwork, end of lfe care, discharge planning. Empowered patients and families to participate in care/decision making processes. Effective member of an interdisciplinary team.