Geriatric Social Worker / Case Manager – Older Adult Care | Full-Time (Part-Time may be considered)

The Staff Pad•Lawrence, MA

10d

About The Position

The Geriatric Social Worker / Case Manager supports older adults as they navigate medical, emotional, behavioral health, and social challenges affecting well-being, independence, and quality of life. Working with physicians, nurse practitioners, nurses, patients, families, and community partners, this role coordinates personalized care, connects patients to essential resources, and builds supportive relationships. The position is based in community primary care and involves work in an office, home visits, and senior living communities. The role assesses psychosocial needs and risks, develops care plans, coordinates community resources and transitions of care, provides supportive counseling and behavioral health referrals within professional scope, and supports patients and caregivers dealing with dementia and other age-related care needs. It also contributes to population health and value-based care efforts by engaging high-risk patients, addressing care gaps, documenting care in Athenahealth, participating in case conferences and quality improvement, and advocating for patient preferences, dignity, independence, and quality of life.

Requirements

Bachelor’s or master’s degree in Social Work or a related field from an accredited institution.
Active Massachusetts LSW, LCSW, or LICSW license in good standing.
Experience supporting older adults, medically complex patients, or vulnerable populations.
Strong clinical assessment, communication, organizational, and problem-solving skills.
Ability to work independently and collaboratively within an interdisciplinary healthcare team.
Comfort with community-based visits and communicating with patients and caregivers by phone or video.
Valid driver’s license and reliable transportation for patient visits.

Nice To Haves

Three or more years of experience in geriatrics, primary care, hospital discharge planning, home health, hospice, or community-based care management.
Experience supporting patients with dementia and their caregivers.
Experience in an Accountable Care Organization (ACO), population health, or value-based care setting.
Experience with Athenahealth or a similar electronic medical record.
Knowledge of Massachusetts elder services, MassHealth, Medicare, and community resources.
Familiarity with motivational interviewing, brief behavioral health interventions, and interdisciplinary care planning.

Responsibilities

Assess older adults’ living situations, cognitive and emotional health, caregiver support, finances, and social needs.
Identify risks related to social isolation, mental health concerns, elder abuse, self-neglect, caregiver burnout, and loss of independence.
Develop personalized care plans with patients, families, and the primary care team.
Guide patients and families through dementia, declining function, and changing care needs.
Connect patients with home care, transportation, meal programs, housing, elder services, and financial assistance.
Partner with Massachusetts Aging Services Access Points (ASAPs), elder service organizations, home health agencies, hospitals, rehabilitation facilities, and community programs.
Coordinate transitions from hospitals and skilled nursing facilities to home or senior living communities.
Help patients navigate Medicare, Medicaid/MassHealth, and other benefit programs.
Address social barriers contributing to avoidable emergency department visits, hospitalizations, and poor health outcomes.
Screen for depression, anxiety, substance use, caregiver distress, and other behavioral health concerns.
Provide supportive counseling, brief interventions, and appropriate mental health referrals within professional scope.
Support patients with Alzheimer’s disease and other dementias while educating and counseling family caregivers.
Assist with advance care planning, healthcare proxy documentation, goals-of-care discussions, and appropriate palliative or hospice referrals.
Collaborate with the primary care team to address complex medical, behavioral, and social needs.
Identify and proactively engage high-risk and medically complex patients.
Partner with clinicians and care managers to reduce avoidable emergency department visits and hospitalizations.
Address care gaps related to social needs, behavioral health, and access to medical services.
Document assessments, interventions, referrals, and follow-ups in Athenahealth.
Participate in interdisciplinary case conferences and quality improvement initiatives.
Help develop innovative care management programs for older adults.
Build trusted, lasting relationships with patients, caregivers, and families.
Guide families through the emotional, practical, and financial challenges of caring for aging loved ones.
Facilitate communication among patients, families, healthcare providers, and community organizations.
Advocate for patient preferences, dignity, independence, and quality of life.