Are you ready to join a diverse, high-energy, fast-growing healthcare company?
We are looking for an experienced Licensed Clinical Social Worker to join our growing value-based care team.
This role requires frequent weekly travel to patient homes to complete patient home visits.
60% On location (Patient visits at their home or in the practice clinic office)
40% Working from Home
Who We Are And Why We're Different
Our priority is healthy patients. We deliver better outcomes for patients and lower costs for everyone. We are the only value-based kidney care platform led by physicians, which uniquely qualifies us to care for patients holistically. We keep patients healthier longer - at home and out of the hospital. Our mission is to improve outcomes for patients by slowing disease progression and improving quality of life. We do this by putting nephrologists at the center of care and continuing to build on our data, analytics, and deep understanding of kidney care.
The Licensed Clinical Social Worker will be at the forefront of this intensive, adaptive, and patient-focused model. We are looking for social work professionals that understand the importance of the "Quadruple Aim", where high-touch interactions between patient and healthcare provider enhance patient experience, improve health outcomes, reduce costs, and improve the work life of the provider.
This Type Of Intensive Service Provision Will Require Social Work Professionals That
As Licensed Clinical Social Worker you will manage the psychosocial needs of a caseload of patients as they navigate the staged progression of chronic kidney disease (CKD). This will be done by providing disease-specific education in class-based settings, intensive support for complex psychosocial issues and the management of non-medical risk factors as barriers to positive health outcomes. LCSW's will further engage patients considered high risk for advancing CKD progression and unplanned dialysis starts, in one-on-one, in-person home visits, or telehealth encounters, to provide focused education, self-management strategy reinforcement, intensive support, linkage to appropriate resources, and other core social work competencies.
- Can build strong, productive relationships and maintain consistent communication with patients, their families, and providers.
- Manage a caseload of nephrology practice patients and perform clinical needs assessments/complex-case management for high-risk CKD/ESRD patients. The LCSW will focus on addressing psychosocial needs, signs and symptoms of mental health disorders, social determinants of health, and any other risk factors that affect health outcomes. This is done through assessments and care planning during remote engagements and home visits, and the results of validated measurement tools such as:
- The Patient Activation Measure (PAM) for measuring a patient's ability to self-manage their chronic illness.
- The Patient Health Questionnaire (PHQ-9) for identifying signs and symptoms of depression.
- The Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool for measuring patient's community resource needs as they relate to core social determinants of health.
- Assess for suicidality of patients who indicate risk of self-harm on the PHQ9; assist staff w/ concerns to ensure identification and/or suspicion of abuse, neglect and/or financial abuse of vulnerable and/or elderly patients is reported to appropriate authorities.
- Coordinate w/ dialysis SWs to ensure relationship exists w/ ESRD patients; ensure patient awareness of how to engage w/ their dialysis Social worker and dialysis care team.
- Providing education and referrals to appropriate resources
- Assisting with keeping or obtaining insurance coverage
- Assisting patients with understanding their rights and responsibilities
- Providing supportive counseling
- Assisting in informing patients of the importance of treatment participation
- Advanced Directives education.
KDE Topics To Include
Kidney Disease Education (KDE) for all nephrology practice patients taught in coordination with Registered Dietitians from our developed KDE decks and modules. This KDE will be developed in both class-based and individualized forms, made culturally appropriate as warranted, and adapted to fit a variety of learning needs.
- How the kidneys work.
- The physical symptoms of chronic kidney disease and prevention of uremic complications.
- Co-morbid disease management and the meaning of test results/lab work.
- Impairments in functioning and well-being.
- Different treatment options; including the right to refuse treatment.
- The psychological impact of chronic kidney disease and its impact on family, social life, work, and finances
Education & Experience
- Master's Degree in Social Work (Required)
- 1+ years healthcare/medical social work experience
- Nephrology experience preferred
- Have own reliable transportation and driver's license
- Licensed Clinical Social Worker (LCSW) (Required)
Skills- Technical & Linguistic
- Microsoft Office (required)
- Salesforce, AthenaHealth, other pertinent technology platform
- Languages: English (primary), Spanish (secondary) - preferred not required.
- Comfortable with remote work from home and the technology to support that environment
- Comfortable supporting patients at their home, clinic, or in the hospital as needed
- Comfortable teaching and educating new staff members and patients/caregivers
- Health Insurance
- Dental insurance
- Vision insurance
- Life insurance
- Disability insurance
- Paid time off