Position Summary: The Social Worker is a behavioral health professional providing outreach to members. They assist in identifying social determinants of health, barriers to care, providing a linkage to appropriate community resources, and facilitating referral to other services through collaboration. This role works with our Clinical Care Team which includes RN’s, ARNPs, RDs and WCs in order to provide our members with comprehensive quality outcomes. Responsibilities: Complete appropriate Behavioral Health Assessments to collect information to identify psychosocial needs, social determinants of health, and/ or barriers to care using established assessments and relay this information to the Clinical Care Team for care planning Assist in telephonic outreach for purposes of engagement of KHM eligible members Accountable for individual metrics as defined by the leadership Provide actionable interventions and supportive counseling to members and families which could include assistance with housing, finances, utilities, transportation, and mental health barriers Facilitate linkage to appropriate community health/human services and assist with locating wrap-around services available in the community Encourage adherence to provider treatment plan and Clinical Care Team Plan of Care Collaborate with outside agencies to ensure continuity of care Participate and provide updates in team meetings, 1:1 meetings with leadership, and attend in-service training Document in HealthMap’s Care Management Systems as appropriate Perform other related duties as requested Requirements: Master’s degree in social work is required An active, unrestricted, state board-issued LCSW (Licensed Clinical Social Worker) license is highly preferred 3 years of experience in healthcare or human services agency setting Experience in a managed care setting Experience working in the community with knowledge of renal health and/or community resources preferred Skills: Strong interpersonal skills are required to motivate patients and others Excellent written and verbal communication Cultural awareness and knowledge Ability to independently identify problems, clarify facts, and organize information to identify trends, information gaps, or need for additional information Must be proficient in Microsoft Office: Outlook, Word, Excel, PowerPoint Travel: Limited Travel, Scheduled per needs of the business #LI-Remote