Social Worker

What You’ll Do

• Collaborate with interdisciplinary team members, including nurses, dietitians, care coordinators, and others, to deliver comprehensive virtual care services to patients.
• Provide support for patients and families coping with life transitions, chronic illnesses, and other psychosocial challenges.
• Empower patients and caregivers by providing ongoing education regarding psychosocial issues related to kidney disease and all available support services including but not limited to transition to dialysis, conservative care, and advance directives.
• Conduct virtual assessments to identify patients’ social, emotional, and financial needs, with a focus on social drivers of health.
• Develop and implement individualized care plans that address patients' needs, connecting them with relevant community resources such as housing assistance, food programs, financial aid services, etc.
• Manage referrals regarding patients at high risk of poor health outcomes, barriers to complete treatment recommendations, and/or with complex psychosocial barriers.
• Identify root cause(s) of barrier(s), develop plan of intervention with an evidence-based approach, execute intervention, and monitor success of intervention.
• Re-evaluate interventions and plans as necessary.
• Provide supportive counseling services to patients as permitted within the scope of their clinical training and state license.
• Report the discovery of unreported medical or social conditions or changes at home that may lead to adverse outcomes to the clinical team and ensure that these are referred to appropriate sources for attention.
• Advocate for patients by facilitating access to appropriate social services and supporting them through healthcare and social care navigation.
• Maintain thorough and timely documentation of all patient interactions, care plans, and interventions, ensuring compliance with company policies and regulatory requirements.

What You’ll Need

• A Master's degree in Social Work from an accredited program.
• Must hold an active unrestricted Social Worker license in the state of residence.
• Willingness to obtain and maintain additional state licensures as needed, which may require passing the Association of Social Work Boards (ASWB) exam.
• 1+ years of experience in social work, preferably in a healthcare or community-based setting.
• 2+ years’ experience in the delivery of care to patients with CKD, ESKD, or other chronic diseases.
• Knowledge of healthcare regulations (including HIPAA) and a strong commitment to patient confidentiality, ethics, and professional standards.
• Proficient in using virtual care platforms to deliver education, document care, collaborate with interdisciplinary teams, and create a positive, engaging, and impactful patient experience remotely.
• Strong case management skills, with the ability to manage complex patient needs and caseloads effectively in a virtual or remote care environment.
• Deep understanding of social determinants of health, with experience connecting patients to appropriate social, behavioral, and community-based resources.
• Excellent communication and interpersonal skills, with the ability to build trust and collaborate effectively with patients, caregivers, and interdisciplinary care teams remotely.
• Proven ability to advocate for patients and navigate complex healthcare and social service systems to address barriers to care.
• High levels of empathy, emotional intelligence, and sound judgment when supporting patients and caregivers through challenging or sensitive situations.
• Strong organizational, time management, and problem-solving skills, with the ability to adapt priorities and manage patient care effectively in a remote setting.