Social Worker - Compassionate Care Program

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.

Who You Are

You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change.

Your Role

As a Compassionate Care Program Social Worker with Evergreen Nephrology, you will play a critical role in delivering patient-centered, value-based care to individuals with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). This role focuses on advanced care planning, establishing patient-centered goals of care, addressing SDoH needs, assisting with behavioral health needs, and facilitating timely hospice and palliative care referrals.

The Social Worker collaborates closely with nephrologists, nurses, care coordinators, and interdisciplinary team members to ensure care aligns with patient values, improves quality of life, reduces avoidable utilization, and supports high-quality outcomes under value-based care arrangements.

While this position is fully remote, you will support patients in all time zones Monday-Friday 8:30a-5p (CST preferred).

Role Responsibilities

Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following:

• Advanced Care Planning & Goals of Care
  • 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.
• Hospice and Palliative Care Coordination
  • 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.
• Patient & Family Engagement
  • Provide counseling on symptom burden, quality of life, and psychosocial impacts of kidney disease.
  • Reinforce understanding of treatment options and support informed decision-making.
• Psychosocial Assessment & Support
  • 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.
• Interdisciplinary & Value-Based Care Collaboration
  • 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.

Required Qualifications

• 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 Qualifications

• 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

Compensation

The pay range for this role is $80,000 to $95,000 annually. Exact pay is determined based on experience, education, demand for the role, and other role-specific factors.

This role is also eligible for an annual bonus.

Benefits

Evergreen Nephrology’s total rewards program is designed to support you in and outside of work. You can expect:

• 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

Evergreen Nephrology is an equal opportunity employer. Applicants will not be discriminated against because of race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, citizenship status, disability, ancestry, marital status, veteran status, medical condition or any other protected category under local, state or federal laws.

If you are an applicant with a disability who requires reasonable accommodation for any part of the hiring process, please contact us for assistance at [email protected].