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-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).

• Work
  Mondayto 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 illness2+ 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

• 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

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