Social Worker

Interwell Health is a kidney care management company that partners with physicians on its mission to reimagine healthcare—with the expertise, scale, compassion, and vision to set the standard for the industry and help patients live their best lives. We are on a mission to help people and we know the work we do changes their lives. If there is a better way, we will create it. So, if our mission speaks to you, join us! The Licensed Social Worker is a key member of the interdisciplinary care team, providing virtual support to patients facing complex medical, social, and behavioral health challenges. In this role, you’ll partner with patients to navigate healthcare and social systems, connect them to critical community resources, and address barriers that impact overall wellbeing. This opportunity is ideal for a mission driven social worker with strong case management experience and a passion for improving patient outcomes in a collaborative, value ‑ based care environment. Note: We are hiring for multiple openings, with preference for candidates who reside in and hold licensure in select states; details will be discussed during the interview process. What You’ll Do: 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. Re-evaluates interventions and plans as necessary. Provides supportive counseling services to patients as permitted within the scope of their clinical training and state license. Reports the discovery of unreported medical or social conditions or changes at home that may lead to adverse outcomes to the clinical team and ensures that these are referred to appropriate sources for attention. Advocate for patients by facilitating access to appropriate social services and supporting them through healthcare and social care navigation. Maintain thorough and timely documentation of all patient interactions, care plans, and interventions, ensuring compliance with company policies and regulatory requirements. What You’ll Need: Master's degree in Social Work from an accredited program. Must hold an active unrestricted Social Worker license in the state of residence Willingness to obtain and maintain additional state licensures as needed, which may require passing the Association of Social Work Boards (ASWB) exam 1+ years of experience in social work, preferably in a healthcare or community-based setting. 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…