Home Health Social Worker Care Manager

Overview

Social Workers are needed for a dynamic, fast-paced start-up with an innovative care management position that is transforming the delivery of kidney care. You will be driving to patients' homes who suffer from chronic kidney disease. We are looking for someone who works well with ambiguity, drive time, and telehealth components. Most patients are suffering from chronic kidney disease (CKD) and end-stage renal disease (ESRD).



Requirements:

• Work Monday to Friday 8:00 am to 5:00 pm and occasionally after 5:00 pm
• You must be mission-driving and willing to deal with underserved populations
• Master's Degree in Social Work, behavioral sciences, or another related field
• Currently licensed as an LCSW or LMSW
• 2+ years of experience working in care management and/or with chronic illness 2+ years of experience working in medical settings such as home health, dialysis, or hospice
• Tele-health! Ability to take calls remotely on some nights and weekends
• Self-starter with the ability to work independently with minimal supervision
• Must show empathy and quickly build relationships with patients and CBOs
• Excellent verbal communication skills both in person and on the phone
• Must be fully vaccinated
• Must be willing to travel to the patient's home

Perks:

• Competitive compensation, of $65,000
• Flexible paid leave (PTO), sick days, and vacation policy
• Full Benefits (Medical, Dental, & Vision)
• 401K Plan
• Laptop & Phone Allowance (if applicable details will be discussed)
• Internal Growth Opportunities

Job Descriptions:

• Lots of driving! This position will cover a two-hour travel radius.
• Rare domestic travel may be required to headquarters in Nashville, TN
• Ability to occasionally visit patients or take calls remotely on some nights and weekends
• Work with Microsoft Office and mobile phone and web-based applications
• Perform in-home care management visits to assess and impact their social and behavioral status
• Work closely with Care Team to ensure continual progress on all care management goals
• Assess social determinants of health needs and develop a plan for addressing them
• Perform behavioral, environmental, and social support assessments and surveys
• Deliver individual, family, and group education on living with chronic illness
• Engage family and social support groups in the education and care of patients
• Assess patients and refer them to behavioral health specialists for diagnosis and treatment Help patients to understand accept and follow medical and lifestyle recommendations
• Serve as the point of contact for patient questions regarding social and behavioral
• Facilitate conversations around and consideration of proactive care decisions, especially relating to transplantation, home modalities, and AV fistula placement
• Initiate patient relationships through enrollment and onboarding processes
• Document patient updates and progress in the EMR
• Identify, vet, and build relationships with local Community-Based Organizations
• Introduce patients to appropriate resources and act as the patient advocate
• Serve as subject matter expert on social determinants for other members of the Care Team

Interview Process:

• Brief screening call with a talent advisor
• Phone Interview with HR
• Video Zoom interview the operations manager and leadership