Care Manager - Social Work

• 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
  
• Ability to visit patients occasionally or take calls remotely on some nights and weekends
  
• Excellent verbal communication skills both in person and on the phone
  
• Be able to work with Microsoft Office and mobile phone and web-based applications
  
• Perform in-home care management visits to assess and impact 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 to behavioral health specialists if diagnosis and treatment needed
  
• 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
  
• Review and document patient updates and progress in 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
  

Requirements

• Master s Degree in Social Work, behavioral sciences or another related field
  
• Currently licensed as a LCSW or LMSW in the State of MD
  

• 2+ years previous experience working in care management and/or with chronic illness within a medical environment home health, dialysis, hospice
  
• Ability to take calls remotely on some nights and weekends
  
• Self-starter with the ability to work independently with minimal supervision
  
• Want to work for a start up
  
• Works well with ambiguity, drive time, tele-health components
  

Benefits

• Opportunity to work in a dynamic, fast paced and innovative care management company that is transforming the delivery of kidney care
  
• Competitive compensation package including salary
  
• Flexible paid leave and vacation policy