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 b 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 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 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)

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 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