Role Overview

Join a multidisciplinary team (MDT) comprising doctors, nurses, allied health professionals and community volunteers to deliver holistic social work services to End-Stage Renal Disease (ESRD) patients and their families. You will play a key role in supporting patients’ psychosocial well-being, facilitating access to care, and enhancing their quality of life through case management and programme development.

Key Responsibilities

1. Case Admission & Assessment

• Manage the end-to-end referral and admission process, including intake screening, financial counselling, and dialysis slot allocation
• Conduct comprehensive psychosocial assessments and develop individualised care plans for patients and their families
• Collaborate with internal MDT members and external referral partners to ensure smooth care transitions
• Provide orientation and emotional support to newly admitted patients to ease adjustment into the dialysis centre

2. Case Management

• Perform regular patient check-ins during dialysis sessions to monitor well-being and build therapeutic relationships
• Identify and proactively intervene in cases of psychosocial risks, treatment non-adherence, or financial challenges
• Conduct home or hospital visits where required to better assess patient needs and family dynamics
• Develop, implement, and review care plans for complex or high-risk cases
• Advocate for patients and connect them with appropriate community resources and social services

3. Programme Planning & Implementation

• Design and deliver patient-centric programmes and psychoeducation sessions to enhance well-being and social integration
• Coordinate programme logistics including venue setup, registration, volunteer involvement, and speaker engagement
• Monitor and evaluate programme outcomes, incorporating feedback for continuous improvement

4. Volunteer Engagement & Supervision

• Serve as the main liaison for befriender volunteers, including onboarding, training and ongoing support
• Review volunteer interaction records and follow up on cases requiring intervention
• Organise and coordinate volunteer participation in programmes, outreach and centre activities
• Provide supervision to ensure safe, effective, and meaningful volunteer engagement
• Support volunteer engagement initiatives and provide feedback to management on programme effectiveness

5. Documentation & Reporting

• Maintain accurate and timely case documentation in line with organisational and professional standards
• Prepare regular reports on programme outcomes and social service activities for management review
• Support audit processes and compliance requirements through proper documentation and participation in reviews

Requirements

• Degree in Social Work or equivalent (recognised by SASW)
• Relevant experience in medical or community social work preferred
• Strong interpersonal, communication and organisational skills
• Ability to work collaboratively in a multidisciplinary setting