Kidney Social Services Case Manager

DUTIES AND RESPONSIBILITIES: 

The Master's Level Social Worker (MSW) will be at the forefront of this intensive, adaptive, and patient-focused model. Adobe Care and Wellness are looking for social work professionals that understand the importance of the “Quadruple Aim”, where high-touch interactions between patient and healthcare provider enhance the patient experience, improve health outcomes, reduce costs, and improve the work-life of the provider.

As an MSW, you will manage the psychosocial needs of a caseload of patients as they navigate the staged progression of chronic kidney disease (CKD). This will be done by providing disease-specific education on (CKD), intensive support for complex psychosocial issues, and the management of non-medical risk factors as barriers to positive health outcomes. MSW’s will further engage patients considered high risk for advancing CKD progression and unplanned dialysis starts, in one-on-one, in-person home visits, or telehealth encounters, to provide focused education, self-management strategy reinforcement, intensive support, linkage to appropriate resources, and other core social work competencies. 

Duties: 

• Build strong, productive relationships and maintain consistent communication with patients, their families, and providers.
• The MSW will manage a caseload of nephrology patients and perform monthly clinical needs assessments/complex-case management for high-risk CKD/ESRD patients. 
• The MSW will focus on addressing psychosocial needs, signs, and symptoms of mental health disorders, social determinants of health, and any other risk factors that affect health outcomes. This is done through assessments and care planning during remote engagements and home visits, and the results of validated measurement tools such as:
  • The Patient Activation Measure (PAM) for measuring a patient’s ability to self-manage their chronic illness.
  • The Patient Health Questionnaire (PHQ-9) for identifying signs and symptoms of depression.
• Educate patients on kidney disease. Topics to include but not limited to the following:
  • How the kidneys work.
  • The physical symptoms of chronic kidney disease and prevention of uremic complications.
  • Co-morbid disease management and the meaning of test results/lab work.
  • Impairments in functioning and well-being.
  • Different treatment options; including the right to refuse treatment.
  • The psychological impact of chronic kidney disease and its impact on family, social life, work, and finances.
• Act as a patient’s advocate, liaison, and information resource; escalating all appropriate information to their nephrologist as appropriate. 
• Assess and assist patients for linkage and utilization of appropriate community resources with a focus on complex psychosocial needs in conjunction with other members of the care coordination team.
• Complete timely and accurate documentation per company-documented procedures and relevant professional and regulatory standards
• Perform other duties and responsibilities as required, assigned, or requested.

 QUALIFICATIONS: 

Education & Experience:

• Master’s (Required)
• 1 years healthcare/medical social work experience
• Nephrology experience preferred

Skills- Technical & Linguistic:

• Microsoft Office (required)
• Salesforce

Languages: English (primary), Spanish (secondary) – preferred not required