The Clinical Social Worker will serve as a member of a multi-disciplinary staff team with nurse care managers and community health workers to identify and intervene with high risk/high cost patients at assigned sites. This position will have a smaller regular assignment and cover for care managers during leaves, vacations, vacancies, and high need. Care management teams support high risk/high cost patients to utilize the healthcare system optimally and engage effectively in their individualized health plan. Identified patients will likely carry two or more co-morbid diagnoses which may include psychiatric illness, alcoholism and/or substance abuse.
Job Purpose: Works in partnership with complex care management team to screen high risk/high utilization patients. Conducts comprehensive assessments of patients to identify drivers of poor health outcomes and developed individualized care management plan in collaboration with patient and care team. Works with payers, caregivers and staff beyond immediate CCM team to provide systemically informed care and health management for individual patients with complex needs. Links and collaborates with staff at anchor service site, to foster a meaningful and collaborative approach to health management for identified patients. Demonstrates a capacity to participate in a collaborative multi-disciplinary team process, with an ability to establish a meeting agenda and support the team through care planning for multiple patients with psychosocial, behavioral and medical needs. Identifies and manages risk for specific populations, eg. homeless, substance using, elders, disabled. Works with CM manager on assigned short and long term projects to support the care management clinical teams and processes. May include home/community based visits and coordination with ambulatory locations.
Master's degree in Social Work or an equivalent related degree.
Current MA licensure as LICSW (Licensed Independent Clinical Social Worker) or eligibility for licensure. LCSW (Licensed Clinical Social Worker) is adequate when pursuing required supervisory hours in order to be eligible to register for LICSW exam within 1 year of hire. CCM certification or equivalent preferred.
Minimum of two years post master's degree, in clinical or human service setting with relevant populations. Bicultural and/or bilingual candidates (Spanish, Portuguese, Haitian Creole or others) preferred. Experience providing compassionate, respectful care with low income populations with mental illness and addictions strongly preferred. Understanding of medical care and chronic disease and treatment preferable. Must be self-directed, and able to function collaboratively in a team environment. Strong computer skills, including Microsoft Word, Excel, and EMR (Epic) skills highly desirable.