Address
Form of workJob Description
Roles and Responsibilities
Position Requirements
Benefits
- 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
- Initiate patient relationships through enrolment 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
Position Requirements
- This position involves car travel to patients' homes, allows a remote work after home visits
- Currently licensed as a LCSW or LMSW in MI
- Master's Degree in Social Work, behavioral sciences, or another related field
- 2+ years previous experience working in care management and/or with chronic illness
Benefits
- Opportunity to work in a dynamic, fast-paced and innovative value-based provider organization that is transforming the delivery of kidney care
- Competitive salary
- Comprehensive medical, dental, vision and life insurance
- Flexible paid leave and vacation policy
- 401(k) plan with matching contributions
