Social Worker

Overview

Required skills and experience: -Bachelor’s degree in Social Work · At least 12 months clinical experience. State licensure or certification required if licensure or certification is available in the state where the local market is located · Experience in caring for kidney care patients · Experience with team-based care, excellent collaboration skills · Excellent working knowledge of community resources. · Exceptional capacity to multitask · Self-directed · Comfort with ambiguity · Strong communication and teaching skills · Daily access to a vehicle with valid driver’s license What you need to know: As a Social Worker with our company, you will own the behavioral health care plan for your patients, partnering with the Behavioral Health Advance Practice Provider and the interdisciplinary team to ensure this aspect of the care plan is integrated into the full care plan. Primary functions for this role include: · Comprehensive management of behavioral health needs, including assessment, diagnosis, treatment, and consultation, on a longitudinal basis, which minimizes the avoidable hospital admissions · Provide transitions of care support via collaborative pathways with inpatient, post-acute care facilities and dialysis centers, to ensure strong social support and behavioral health care plans as part of the overall transition of care plan · Partner with Evergreen Nephrology’s care team to identify and eliminate social determinants of healthcare for your patients, including functional capacity, home environment, health literacy, housing instability, food insecurity, and caregiver support and in- home support service in care planning · Participate in ongoing scheduled consultation with an interdisciplinary team to monitor patient progress · Link patients to community resources as appropriate · Support patients through direct telephonic and video behavioral health care for patients with a higher level of behavioral health acuity · Accurately identify and document behavioral health conditions and establish holistic treatment plan for the respective conditions · Cogently explain the Evergreen Nephrology IDT resources and clinical programs to patients and families; guide patients toward quality-of-life decisions aligned with patient goals and values. Recognize goal-directed care in response to patient needs is an important component of managing psychiatric conditions. - Represent Evergreen Nephrology commendably to patients, families, providers, and community

Qualifications

• Bachelor's degree or higher
• Valid Licensed Clinical Social Worker (LCSW)
• 1+ years of experience in ANY of the following:
  • clinical experience
  • kidnay care patients
  • value based care
• Are you comfortable working in a Start-up environment?

• What is your salary expectation for this role?

Company

Our client is a Hospital & Healthcare Company who partners with nephrologists to transform kidney care and improve patient outcomes. They believe that patients living with kidney disease deserve the best care and they are passionate about making an impact. When nephrologists are empowered, they are enabled to transform kidney care for their patients and partner with their patients on earlier identification of alternative modalities, slowing of disease progression, improved clinical outcomes, and increased quality of life.