Social Worker

About the Role

Duo Health is seeking a proactive, compassionate, and self-motivated Social Worker to join our team in San Juan, Puerto Rico.

As a Social Worker, you will be a key member of an interdisciplinary care team consisting of a Nurse Practitioner, Social Worker, Patient Experience Specialist, and RN Care Navigator. You will work closely with your team to provide high-touch, personalized support to a designated panel of patients living with chronic kidney disease.

This is a field-based, patient-facing position. You will regularly engage with patients in their homes and in the community, as well as by phone and telehealth. The role requires reliable transportation and the ability to drive throughout the San Juan area for in-person patient visits.

You will build strong relationships with patients and families, identify barriers that may impact their health, connect them with community resources, and provide psychosocial support that helps them successfully navigate their healthcare journey.

Key Responsibilities

• Manage a designated panel of patients and provide ongoing psychosocial support and case management.


• Collaborate closely with the Nurse Practitioner, RN Care Navigator, and Patient Experience Specialist to develop and coordinate individualized patient care.


• Conduct in-person visits with patients in their homes and community settings throughout the San Juan area.


• Drive to patient homes and other community locations as needed to support patient care.


• Build trusting relationships with patients and caregivers while understanding their individual social, emotional, behavioral, and practical needs.


• Identify and address barriers to care, including transportation, housing, food insecurity, financial challenges, behavioral health needs, and access to healthcare.


• Connect patients and families with appropriate community resources, social services, behavioral health providers, and other support programs.


• Coordinate with health plans, behavioral health providers, social service agencies, community organizations, and healthcare providers.


• Provide short-term Screening, Brief Intervention, and Referral to Treatment (SBIRT) services as appropriate.


• Participate in interdisciplinary care team meetings, case reviews, and care planning.


• Develop and maintain individualized care plans in collaboration with the patient and care team.


• Educate patients and care team members regarding available social, behavioral health, and community resources.


• Maintain accurate, timely, and thorough documentation of patient encounters and interventions.


• Participate in quality improvement initiatives and contribute to the development of clinical workflows and best practices.


• Follow all applicable company policies, procedures, and clinical standards.

Requirements

• Licensed Clinical Social Worker (LCSW) or Licensed Master Social Worker (LMSW) in Puerto Rico.


• Experience providing clinical social work, case management, or psychosocial services.


• Experience working directly with patients and families in healthcare, community, behavioral health, or social service settings.


• Valid driver's license, reliable personal transportation, and ability to drive throughout the San Juan area for in-person patient visits.


• Comfortable conducting home and community-based visits and working with patients in a variety of environments.


• Ability to work independently while maintaining strong communication and collaboration with an interdisciplinary care team.


• Strong communication, interpersonal, organizational, and documentation skills.


• Ability to establish trusting and inclusive relationships with patients, caregivers, and colleagues.


• Experience connecting individuals and families with community resources and social services.


• Strong commitment to patient-centered care, health equity, and improving outcomes for individuals with chronic conditions.


• Bilingual Spanish and English communication skills.

Preferred Qualifications

• Experience working with individuals with chronic kidney disease or other complex chronic conditions.


• Experience working with underserved or diverse populations.


• Familiarity with healthcare and social service resources in Puerto Rico.


• Experience providing home-based or community-based services.


• Candidates who live in or have strong familiarity with the San Juan community are encouraged to apply.