Social Worker

The Social Worker coordinates and supports patient care, especially for individuals with chronic or complex medical needs. The Social Worker is responsible for supporting the following: Remote Patient Device Program ("RPM"), Chronic Care Management ("CCM") and Principal Care Management ("PCM") for patients and Value Based Care teams for all KCC Clinics. The Social Worker also ensures that all eligible patients are enrolled in all applicable programs by being a liaison between the corporate team and the clinic team.

• Manage: PHQ-9 patients primarily operate in integrated care, medical, or behavioral health settings. The role involves screening for depression, tracking symptom severity, providing brief interventions, and coordinating care to improve mental health outcomes.
• Assessment & Planning: Conduct comprehensive evaluations of patients' medical, social, and emotional needs, and develop personalized care plans aligned with clinical goals.
• Care Coordination: Liaise with doctors, nurses, therapists, community agencies, and other providers to ensure seamless service delivery.
• Monitoring & Follow-Up: Track patient progress between visits, review symptoms, medication compliance, and vital signs; escalate concerns promptly.
• Advocacy: Help patients navigate the healthcare system, access necessary services, and resolve barriers such as transportation or cost.
• Education & Support: Provide clear, tailored information about conditions, treatments, and self-care; offer emotional support to patients and families.
• Documentation: Maintain accurate, confidential client records and update all relevant stakeholders on changes in care plans.
• Community Linkage: Connect patients with social services, nutrition programs, or other community resources to support ongoing care.

• Other duties, as assigned.

• Ability to communicate with patients/customers at all levels via telephone.
• Ability to follow HIPAA guidelines and regulations.
• Must have technological competence for computer use.
• Must be proficient with; MS Word, MS Excel, Email and Internet usage and Company EMR.
• Must be able to sit for extended period of time
• Experience in a call center environment is a plus but not mandatory.

• Regularly uses a keyboard to interact with computer system.
• Regularly sits for extended periods of time.
• Regularly proofreads and/or reviews documents.

• Responsible for supporting the values and customer service standards of KCC.
• Accountable for outstanding customer service to all staff, patients, clients and vendors.
• Develop and maintain effective relationships through effective and timely communication.
• Initiate actions to respond, resolve and follow up regarding customer service issues with all customers and patients in a timely manner.

• Bachelors in social work (BSW) required.

• Skills: Strong communication, problem solving, and interpersonal abilities; attention to detail; ability to operate office and field equipment.
• Strong working knowledge of chronic diseases including chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure and basic medical management.
• Must be highly motivated, result-oriented with strong skills in presenting, communicating, organizing, multi-tasking and time management skills.
• Strong organizational and interpersonal skills
• Excellent customer service skills demonstrated by positive feedback from patients/team.
• Ability to identify problems and recommend solutions.
• Ability to read write and communicate effectively orally and in writing.
• Basic computer skills including previous work with an electronic health record (EMR)

• Any other language in addition to English is preferred.

• Monday - Friday with Saturdays availability also.

• Full-Time and Part-Time available.