Social Worker
$65,000–$65,000 year
On-siteSanford, North Carolina, United States
Job Summary
Conduct in-home care management visits to assess and impact social and behavioral status for patients with chronic kidney disease and end-stage renal disease. Perform behavioral, environmental, and social support assessments, then deliver individual, family, and group education on living with chronic illness. Act as the patient advocate by identifying resources, vetting Community-Based Organizations, and referring patients to behavioral health specialists as needed. Facilitate proactive care decisions regarding transplantation, home modalities, and AV fistula placement while documenting updates in the EMR. Work Monday through Friday with occasional evening telehealth calls and rare domestic travel to Nashville, TN. Requires a Master's degree, LCSW/LMSW license, and two years of experience in care management or medical settings.
Required Qualifications
- 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
- 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 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
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