The Value-Based Care Management Social Worker provides telephonic social services to patients and their families in a timely and efficient manner to promote maximum social functioning and psychological adjustment to dialysis and rehabilitation of the patient.
Essential Duties and Responsibilities include the following. Other duties and tasks may be assigned.
Complete initial assessment of new patient psychosocial needs in adherence to state/CMS regulations and company policy.
Provide ESRD treatment options education to patient and social support system.
Provide patients with external resources, and support to improve Social Determinants of Health, and Quality measures.
Review the need for and assistance with obtaining DME, home health and other resources necessary for the patient and educate them about their community resources and options and advocating on behalf of the patient.
Collaborate with market Social Worker and patients, Physician and specialist as needed and provide related feedback on planned interventions and outcomes of plan of care.
Participate as a member of the Interdisciplinary team in all required patient assessment and care planning activities as needed.
Identify social agencies and other resources as appropriate to the needs of the patients, including but not limited to financial/funding sources.
Be familiar with professional organizations related to kidney disease (i.e., National Kidney Foundation, American Kidney Foundation).
Maintain knowledge of and comply with federal, state, local laws and regulations, including health care professionals practice act requirements.
Perform duties at all times within limitations established by and in accordance with company policy and procedures, applicable state and federal laws and regulations.
Actively promote GUEST customer service standards; develop effective relationships at all levels of the organization.
Participate in team concepts and promote a team effort; perform duties in accordance with company policies and procedures.
Regular and reliable attendance is required for the job.
