Care Manager - Social Worker

Position: Social Worker 

**This position requires an active LCSW in the state of application.**

As a social worker, you are an integral part of building trusting relationships with patients, so that they can experience a high quality of life at home. Work with a small panel of patients where you can experience directly the impact of your care.

At Monogram Health, our mission is to transform the way health care is delivered for those with kidney disease so they can lead healthier, happier, and more fulfilling lives. This transformation is urgently needed. In our healthcare system, the patient has too often become secondary due to processes and incentives that don’t positively impact the patient for the long term. 

The Care Manager - SW is a key member of an integrated Care Team which includes a Nurse Care Manager and an Advanced Practice Provider.  The patients we serve often struggle with multiple serious diseases and behavioral health challenges. Social workers can remove the many economic and behavioral barriers to patients, enabling positive health outcomes. 

The care team works with patients face-to-face, over the phone, and through telehealth to identify and address social determinants of health, build up and engage a patient’s social support network, navigate behavioral challenges, and generally help patients through a traumatic diagnosis and life-changing disease.  

Roles and Responsibilities 

• 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 social and behavioral questions from patients  
• Facilitate conversations around and consideration of proactive care decisions, especially relating to transplantation, home modalities and AV fistula placement 
• Initiate patient relationships through enrolment 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  

 Position Requirements 

• This position involves car travel to patients’ homes 
• Currently licensed as a LCSW or LMSW in the posted state 
• Rare domestic travel may be required to Brentwood, TN 
• Self-starter with the ability to work independently with minimal supervision 
• Ability to show empathy and quickly build relationships with patients and local CBOs 
• Master’s Degree in Social Work, behavioral sciences, or another related field 
• 2 years previous experience working in care management and/or with chronic illness 
• Ability to occasionally visit patients or take call remotely on some nights and weekends 
• Excellent verbal communication skills both in person and on the phone 
• Familiarity with Microsoft Office and mobile phone and web-based applications 

 Benefits 

• Comprehensive medical, dental, vision and life insurance 
• Paid vacation and holiday time
• 401(k) plan with matching contributions (employer match vested 100% from day 1)
• Pet Insurance
• Company paid life insurance
• FSA & HSA

About Monogram Health 

Monogram Health is a value-based chronic condition organization serving patients with chronic kidney and end-stage renal disease and their related metabolic disorders. Monogram seeks to transform the way nephrology, primary care and chronic condition treatment is delivered. Monogram’s in-home approach utilizes a national nephrology practice supported by case and disease management, utilization management and review, and medication therapy management services that improve health outcomes while lowering medical costs. By increasing access to evidence-based care pathways and addressing social determinants of health, Monogram has emerged as an industry leader in championing health equity and improving health outcomes for individuals with chronic kidney and end-stage renal disease. 

At Monogram Health we believe in fostering an inclusive environment in which employees feel encouraged to share their unique perspectives, leverage their strengths, and act authentically. We know that diverse teams are strong teams, and welcome those from all backgrounds and varying experiences.