Evergreen Nephrology · 1 day ago
Social Worker - Compassionate Care Program
United States
Full-time
Remote
Entry, Mid Level
$80K/yr - $95K/yr
2+ years expEvergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered approach. As a Compassionate Care Program Social Worker, you will deliver patient-centered care to individuals with chronic kidney disease, focusing on advanced care planning and collaboration with interdisciplinary teams.
Health CareMedicalWellness
Responsibilities
Facilitate advance care planning conversations, including advance directives, POLST/MOLST forms as appropriate, and designation of healthcare proxies
Lead and document goals-of-care discussions that align medical treatment with patient values, preferences, and prognosis
Support patients and families through complex decision-making related to dialysis initiation, conservative management, and end-of-life care
Work with ECCP NCM to help identify patients appropriate for palliative care and hospice services based on clinical status, prognosis, and patient goals
Educate patients and families on the role, benefits, and timing of palliative care and hospice
Facilitate referrals and coordinate transitions to hospice and palliative care providers
Collaborate with external agencies to ensure seamless, patient-centered transitions of care
Provide counseling on symptom burden, quality of life, and psychosocial impacts of kidney disease
Reinforce understanding of treatment options and support informed decision-making
Conduct psychosocial assessments to identify barriers to care, including social determinants of health, caregiver stress, mental health concerns, and financial or housing instability
Provide emotional support, counseling, and crisis intervention as needed
Connect patients and families to community resources and supportive services
Participate in interdisciplinary team meetings, case conferences, and care planning discussions
Collaborate with clinical and operational partners to reduce unnecessary hospitalizations and emergency department utilization
Support quality metrics, patient experience goals, and cost-effective care delivery consistent with value-based care models
Maintain accurate, timely documentation to support clinical quality, compliance, and reporting requirements
Other duties consistent with this role, as assigned
Qualification
Required
Master's degree in Social Work (MSW)
Active state social work licensure
At least 2 years of experience working in a healthcare field
Strong skills in advanced care planning and goals-of-care discussions
Excellent communication, counseling, and interdisciplinary collaboration skills
Intermediate skills with MS Office Suite of products including Outlook and Teams
Able to work effectively in a primarily remote environment: Home internet must support a minimum download speed of 25 Mbps and upload speed of 10 Mbps. Cable, Fiber, or DSL connections hardwired to the internet device are recommended
Evergreen will provide remote employees with telephony applications and equipment to meet the business requirements for their role
Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Preferred
Experience working with patients with chronic or end-stage kidney disease
Familiarity with value-based care models, population health, or care management programs
Training or certification in palliative care or end-of-life care
Knowledge of Medicare, hospice eligibility criteria, and community-based resources
Benefits
Paid time off starting at 4 weeks for full-time employees
12 paid holidays per year
Medical, dental, vision and life insurance, including an HSA with employer match
Reimbursement for continuing medical education for eligible roles
A 401(k) program where Evergreen matches up to 4% of contributions
Paid parental leave
A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology
Company
Evergreen Nephrology
Evergreen helps nephrologists focus on the right patients at the right time across the full care spectrum.
201-500 employees
Funding
Current Stage
Growth StageTotal Funding
$134.34M2025-01-07Series Unknown· $130M
2022-06-06Seed· $4.33M
Leadership Team
John E. Donlan
Board Member and Strategic Advisor
Recent News
2025-07-05
2025-01-10
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