Required skills & experience

1. Master's Degree in Social Work, behavioral sciences or another related field

2. Currently licensed as a LCSW or LMSW in the State of NC

3. 2+ years previous experience working in care management and/or with chronic illness within a medical environment i.e. home health, dialysis, hospice

4. Ability to take call remotely on some nights and weekends

5. Self-starter with the ability to work independently with minimal supervision

What You Need to Know:

1. Opportunity to work in a dynamic, fast paced and innovative care management company that is transforming the delivery of kidney care

2. Competitive compensation package including salary

3. Flexible paid leave and vacation policy

4. This position will cover a two-hour travel radius.

5. Looking for someone who works well with ambiguity, drive time, tele-health components

6. This person has to want to work for a start up

Additional Job Details:

1. This position will cover a two-hour travel radius.

2. Rare domestic travel may be required to Nashville, TN

3. Self-starter with the ability to work independently with minimal supervision

4. Ability to show empathy and quickly build relationships with patients and local CBOs

5. Ability to occasionally visit patients or take call remotely on some nights and weekends

6. Excellent verbal communication skills both in person and on the phone

7. Be able to work with Microsoft Office and mobile phone and web-based applications

8. Perform in-home care management visits to assess and impact social and behavioral status

9. Work closely with Care Team to ensure continual progress on all care management goals

10. Assess social determinants of health needs and develop a plan for addressing them

11. Perform behavioral, environmental and social support assessments and surveys as needed

12. Deliver individual, family and group education on living with chronic illness

13. Engage family and social support groups in the education and care of patients

14. Assess patients and refer to behavioral health specialists if diagnosis and treatment needed

15. Help patients to understand, accept and follow medical and life style recommendations

16. Serve as the point of contact for patient questions regarding social and behavioral

17. Facilitate conversations around and consideration of proactive care decisions, especially relating to transplantation, home modalities and AV fistula placement

18. Initiate patient relationships through enrollment and onboarding processes

19. Review and document patient updates and progress in care management platform

20. Identify, vet and build relationships with local Community-Based Organizations

21. Introduce patients to appropriate resources and act as the patient advocate

22. Serve as subject matter expert on social determinants for other members of the Care Team