Opportunity to work in a dynamic fastpaced and innovative care management company that is transforming the delivery of kidney care.
34 Days of Home Visits (within 1 Hour Radius of Assigned Territory) and 12 Days of Telehealth
Coordinating Services for the underserved population not providing direct therapy
Competitive salary and bonus.
Flexible paid leave and vacation policy.
Laptop mileage reimbursement phone allowance and extra perks available!
Responsibilities
Perform inhome 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 CommunityBased 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
Occasionally visit patients or take call remotely on some nights and weekend
Requirements
Masters Degree in Social Work behavioral sciences or other related field
Must be a Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker(LMSW) in the State of New Mexico
2 years previous experience working in care management and/or with chronic illness within a medical environment i.e. home health dialysis hospice
Ability to show empathy and quickly build relationships with patients and local CBOs
Ability to occasionally visit patients or take call remotely on some nights and weekends
Must be fluent in Spanish
Excellent verbal communication skills both in person and on the phone
Ability to work with Microsoft Office and mobile phone and webbased applications
Selfstarter with the ability to work independently with minimal supervision
Must be a road warrior! A lot of driving involved.
Ability to travel to company main location in Nashville for training if necessary
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