Care Manager - Social Work

About the job Care Manager - Social Work Required skills & experience

• Masters Degree in Social Work, behavioral sciences, or another related field.
• Currently licensed as an LCSW or LMSW in the State of MA
• 2+ years of previous experience working in care management and/or with chronic illness within a medical environment in home health or hospice.
• Ability to take calls remotely on some nights and weekends.
• Self-starter with the ability to work independently with minimal supervision.

• Opportunity to work in a dynamic, fast-paced, and innovative care management company that is transforming the delivery of kidney care.
• Competitive compensation package.
• Flexible paid leave and vacation policy.
• This is a full-time position in Home Health with frequent travel
• Laptop, mileage reimbursement, phone allowance, and extra perks are available!

• This position works within a 2-hour travel radius.
• Rare domestic travel may be required to Nashville, TN
• Self-starter with the ability to work independently with minimal supervision
• Ability to show empathy and quickly build relationships with patients and local CBOs
• Perform in-home care management visits to assess and impact the 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 as needed
• 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 if diagnosis and treatment needed
• Help patients 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
• Review and document patient updates and progress in the care management platform
• 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

The work schedule is Monday Friday 8 am 5 pm. However, there could be exceptions where a patient does request a visit after 5 pm.