Licensed Clinical Social Worker (LCSW) - Remote IDT

WHO YOU ARE

You are devoted and compassionate, and enjoy being on the front lines of healthcare, changing the lives of your patients. You’re passionate about partnering with an interdisciplinary team to get to the root cause of a patient’s conditions, remove social determinants of healthcare, and ensure the highest possible quality of life and best outcomes for those in your care. You believe patients living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You don’t want to sacrifice quality over quantity, and you aim to provide the same level of care and commitment to your patients that you would to your own family member. You thrive in innovative and evolving environments with high rates of change. You are driven by process improvements. Does this sound like you? If so, we should talk.

WHO WE ARE

Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants.

We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients.

We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today.

YOUR ROLE

As a Social Worker with Evergreen Nephrology, you influence and ensure the best clinical care for your patients. You leverage an integrated technology platform and are complemented by an entire interdisciplinary team including registered nurses, nurse care managers, health coaches, dieticians, pharmacists, psychiatrists, advanced practice clinicians, other social workers, and even other medical specialists – all within the Evergreen Nephrology family.

This is a remote position that will support multiple markets and IDTs as needed; however, preference will be given to specific state licenses.

PRIMARY FUNCTIONS

As a Social Worker with Evergreen Nephrology, you will own the behavioral health care plan for your patients, partnering with the Behavioral Health Advance Practice Provider or psychiatrist and the interdisciplinary team to ensure this aspect of the care plan is integrated into the full care plan.

• Comprehensive management of behavioral health needs, including assessment, diagnosis, treatment, and consultation, on a longitudinal basis, which minimizes the avoidable hospital admissions
• Provide transitions of care support via collaborative pathways with inpatient, post-acute care facilities, and dialysis centers, to ensure strong social support and behavioral health care plans as part of the overall transition of the care plan
• Partner with Evergreen Nephrology’s care team to identify and eliminate social determinants of healthcare for your patients, including functional capacity, home environment, health literacy, housing instability, food insecurity, and caregiver support and in-home support service in care planning
• Participate in ongoing scheduled consultation with an interdisciplinary team to monitor patient progress.
• Weekly meeting with your market BH APP or psychiatrist to review your active caseload.
• Link patients to community resources as appropriate
• Support patients through direct, telephonic and video behavioral health care for patients with a higher level of behavioral health acuity
• Accurately identify and document behavioral health diagnoses and conditions and establish behavioral health treatment plans for the respective conditions.
• Implement evidenced based psychotherapies.
• Cogently explain the Evergreen Nephrology IDT resources and clinical programs to patients and families; guide patients toward quality-of-life decisions aligned with patient goals and values. Recognize goal-directed care in response to patient needs is an important component of managing psychiatric conditions.
• Represent Evergreen Nephrology commendably to patients, families, providers, and the community
• Other duties as assigned

YOU’RE GOOD AT

• You reviewed the Who You Are section of this job posting and immediately felt the need to read on. That makes you a match for our innovative culture
• You accept that things change quickly in a startup environment and are willing to pivot quickly on