- Opportunity to work in a dynamic, fast-paced and innovative care management company that is transforming the delivery of kidney care.
- 3-4 Days of Home Visits (within 1 Hour Radius of Assigned Territory) and 1-2 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
- 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
- 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 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
- Occasionally visit patients or take call remotely on some nights and weekend
- Master's 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 web-based applications
- Self-starter 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
- Must live within 30 miles of Albuquerque
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bilingual social worker - Albuquerque, United States - Registry Ally, Inc.
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Job DescriptionJob Details
