The Care Manager Transplant SW (MSW) is a specialized member of the multidisciplinary transplant team responsible for providing comprehensive psychosocial assessment, intervention, counseling, education, care coordination, and resource support for solid organ transplant candidates, recipients, living donors as applicable, and their families/caregivers across the continuum of transplant care. This includes outpatient evaluation, waitlist management, inpatient hospitalization, discharge, and post-transplant follow-up.

Conducts comprehensive pre-transplant psychosocial evaluations to assess transplant readiness and identify factors that may impact candidacy or post-transplant outcomes, including mental health, substance use, treatment adherence, coping, caregiver and social support, financial and insurance barriers, housing, transportation, and other social determinants of health. Develops recommendations and interventions to address identified psychosocial barriers.

Participates as a member of the multidisciplinary transplant team and transplant selection committee, providing psychosocial recommendations related to transplant candidacy and readiness. Collaborates with physicians, surgeons, transplant coordinators, financial coordinators, pharmacists, dietitians, and other members of the care team to develop and implement individualized plans of care.

Provides ongoing psychosocial support and intervention throughout the transplant journey, including counseling, crisis intervention, resource coordination, discharge planning, and referrals to behavioral health, substance use treatment, community resources, and other services as appropriate.

Maintains timely documentation of psychosocial assessments, interventions, recommendations, and follow-up plans. Supports transplant program quality improvement, patient education, and compliance with applicable CMS, OPTN, and organizational requirements.

Serves as a transplant-specific psychosocial resource to patients, caregivers, staff, and the multidisciplinary team. Is a mandated reporter for suspected abuse in accordance with applicable law and organizational policy.

Performs other duties as assigned.

Education and Experience

• Master's degree in Social Work (MSW) from an accredited school of social work required.
• Minimum of three (3) years of clinical social work experience in a healthcare setting required.
• Experience conducting comprehensive psychosocial evaluations, including assessment of mental health, substance use, adherence, caregiver support, coping, financial barriers, and social determinants of health required.
• Experience working with medically complex, chronically ill, or end-stage organ disease patients strongly preferred.
• Prior experience in solid organ transplantation, advanced organ failure, dialysis/nephrology, hepatology, cardiology, oncology, or another complex multidisciplinary specialty strongly preferred.
• Experience providing services across both inpatient and ambulatory/outpatient environments preferred.
• Knowledge of transplant psychosocial assessment practices and standardized assessment tools, such as SIPAT or other validated transplant-specific psychosocial assessment methodologies, preferred.
• Knowledge of CMS and OPTN requirements applicable to transplant programs preferred.

Licenses Preferred

Licensed Clinical Social Worker (LCSW) in good standing in the State of California

Certifications Preferred

Transplant-specific professional certification, such as Certified Clinical Transplant Social Worker (CCTSW)

Additional certification or specialized training in behavioral health, substance use disorders, motivational interviewing, crisis intervention, or related areas preferred.