Social Worker

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

Excellent communication and interpersonal skills, with the ability to build trust and collaborate effectively with patients, caregivers, and interdisciplinary care teams remotely.

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.

Empowers 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.

Manages referrals regarding patients at high risk of poor health outcomes, barriers to complete treatment recommendations, and/or with complex psychosocial barriers. Identifies root cause(s) of barrier(s), develops plan of intervention with an evidence-based approach, executes intervention, and monitors success of intervention.