Clinical Social Worker Care Coordinator
5 days ago
Brigham Health Harbor Medical Associates is a leading multispecialty ambulatory practice with multiple locations across the South Shore. Our team of healthcare professionals is dedicated to providing prompt, expert, and compassionate care to patients with complex medical needs.
The OpportunityWe are seeking a full-time Clinical Social Worker Care Coordinator to support patients at our Primary Care sites. As a hybrid opportunity, the position typically covers 1 day a week on-site but requires flexibility to go on-site more when needed. The role involves working closely with high-risk patients to establish, implement, monitor, and evaluate high-quality, cost-effective care plans within the context of our Integrated Care Management Program (iCMP).
Responsibilities:- Reviews and assists in triaging new iCMP patients with the PCP, RN Care Coordinator, and other members of the iCMP team.
- Completes comprehensive bio-psychosocial assessments of patients to evaluate clinical needs, including mental health/psychiatric history/emotional issues/coping style, understanding of illness/adjustment/compliance, barriers to care, cultural issues, abuse and/or neglect, and substance abuse.
- Provides psycho-social assessments of families to determine family relationships/systems as they relate to the care of the patient, identifies family decision-makers and caregivers, and evaluates the family's understanding of illness and trajectory of care.
- Develops comprehensive care plans, utilizing the menu of services available to patients, and provides direct and ongoing care management to select patients or refers to existing care management programs.
- Ensures the timely implementation of the care plan and communicates critical elements of the plan and trajectory of care to the patient, family, and members of the care team.
- Monitors the patient's progress and comprehensive care plan with the aid of internal and external utilization and quality data and guidelines, documents, and reports issues and system barriers.
- Establishes a consistent communication and reporting schedule for periodic contact with providers and patients to review patient status and progress toward goals.
- Evaluates, coordinates, manages, and documents timely and relevant information in patient electronic medical records and the program's identified information technology tool (care management database).
- Identifies key barriers to care and the patient's ability to manage their health and wellness through initial and ongoing assessments.
- Communicates with other healthcare clinicians throughout the continuum about patient care, utilization, and follow-up plans.
- MSW/LICSW or LCSW working toward LICSW
- Five years experience in the field of psychiatry, substance abuse, trauma, and/or community mental health services preferred
- Clinical experience, understanding of, and comfort working with patients of all ages who suffer complex medical and psychiatric problems
- Strong understanding of psychiatric and family systems and ability to use this understanding to formulate succinct case summaries
- Knowledge regarding end-of-life care
- Demonstrated ability to be flexible and adapt to a complex, fast-paced medical environment
Mass General Brigham is an Equal Opportunity Employer. We are committed to diversity, equity, and inclusion in the workplace.
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