Home Health Social Worker Care Manager

About the job Home Health Social Worker Care Manager Overview

Social Workers are needed for a dynamic, fast-paced start-upwith an innovative care management position that is transforming the delivery of kidney care. You will be driv
ing 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

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 Description s:

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 managemen
t 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