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 FL.

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

3. Flexible paid leave and vacation policy.

4. This is a full-time position in Home Health with frequent travel throughout Grand Tampa, FL.

5. Laptop, mileage reimbursement, phone allowance, and extra perks available!

Additional Job Details:

1. This position is in-or-around Tampa with frequent car travel throughout the eastern half of the state

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

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

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

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

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

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

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

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

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

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

15. Initiate patient relationships through enrollment and on boarding processes

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

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

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

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