Clinical Social Worker, Care Coordinator - South Weymouth

Unclassified - Weymouth, MA

Full-time - Mid Level

Remote - Weymouth, MA

About the position

The Clinical Social Worker Care Coordinator at Brigham Health Harbor Medical Associates plays a crucial role in supporting high-risk patients within the Integrated Care Management Program (iCMP). This full-time position involves collaborating with healthcare teams to develop and implement comprehensive care plans, ensuring high-quality, cost-effective care for patients with complex medical and psychiatric needs. The role requires a blend of on-site and remote work, with responsibilities that include patient assessments, care coordination, and advocacy for patients and families.

Responsibilities

• Review and assist in triaging new iCMP patients with the PCP, RN Care Coordinator, and other members of the iCMP team.
• Complete comprehensive bio-psychosocial assessments of patients to evaluate clinical needs.
• File mandated reports when abuse and/or neglect is suspected.
• Provide psycho-social assessments of families to determine family relationships and systems related to patient care.
• Develop comprehensive care plans in collaboration with the Care Team.
• Provide direct and ongoing care management to select patients and refer to existing care management programs as needed.
• Ensure timely implementation of care plans and communicate critical elements to patients, families, and care team members.
• Monitor patient progress and comprehensive care plans using internal and external data and guidelines.
• Establish a communication schedule for periodic contact with providers and patients to review status and progress.
• Evaluate, coordinate, manage, and document relevant information in patient electronic medical records.
• Identify key barriers to care and the patient's ability to manage their health and wellness.
• Communicate with other healthcare clinicians about patient care and follow-up plans.
• Provide necessary iCMP assessments upon discharge from inpatient admissions.
• Offer caregiver/family counseling or support to promote cohesiveness and ability to provide care.
• Prepare patients and families for care transitions, including end-of-life care.
• Advocate for patients and families to gain access to services and resources.
• Coordinate family/team meetings when appropriate.
• Provide consultation to practice staff regarding patients not in the high-risk program.
• Act as a resource to the care team on managing psychosocial and substance abuse issues.
• Collaborate with PCP and/or iCMP Manager and Medical Director on challenging patient situations.
• Attend and present in case reviews, seminars, and program meetings.
• Participate in regular meetings with iCMP Manager and Medical Director to review performance and goals.

Requirements

• MSW/LICSW or LCSW working toward LICSW
• Five years of experience in psychiatry, substance abuse, trauma, and/or community mental health services preferred
• Clinical experience with patients of all ages suffering from complex medical and psychiatric problems
• Strong understanding of psychiatric and family systems
• Knowledge regarding end-of-life care
• Demonstrated ability to be flexible and adapt to a complex, fast-paced medical environment

Nice-to-haves

• Experience in community resources and care management programs
• Familiarity with electronic medical records and care management databases

Benefits

• Health insurance
• Dental insurance
• 401k retirement plan
• Paid time off
• Flexible scheduling options
• Professional development opportunities